Honey Supplement

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Editorial
Richard White
Part I
4 Natural Therapeutic Agents for the
Topical Management of Wounds
Philip Davies, Keith Cutting
14 Recent Clinical Usage of Honey in
the Treatment of Wounds – A Review
Philip Davies
23 The Implications for Honey Dressings
in UK Primary Care
Jackie Stephen-Haynes
26 The Control of Wound Malodour with
Honey-based Wound Dressings and Ointments
Rose Cooper, David Gray
Part II
32 Mesitran Ointment Case Studies
David Gray, Richard White
36 Preliminary Findings of Case Study
Evaluations of Honey Dressings
David Gray, Keith Cutting, Jackie Stephen-Haynes
43 Mesitran Product Focus
Mark Rippon, Philip Davies
50 A Review of the Physical Performance
Characteristics of Honey-based
Wound Dressings and Ointments
Mark Rippon, Darren Jones
welcome to our new wound care factory

Natural Approaches to Wound
Management: a Focus
on Honey and Honey-based
Dressings
Virtually all civilisations worldwide have
at some point relied on natural thera-
peutic agents for primary healthcare;
indeed, some continue to rely on prod-
ucts obtained from natural sources.
Honey, for example, has been used for
many thousands of years in both topical
and oral presentations; plants and their
extracts have provided the basis for
many commonly used drugs; while by-
products of bacteria and fungi, plus
marine flora and fauna provide a prolific
source of novel compounds.
Approximately one-third of all traditional
medicines are used for the treatment
of wounds and skin disorders, compared
to only 1_ 3% of modern drugs.The use
of natural remedies for the treatment
of skin disorders and wounds is based
largely on historical and anecdotal evi-
dence gained over many years. More
recently, the use of these remedies has
played a major part in the development
of new products for the treatment of
a variety of diseases, including chronic
wounds and skin problems. As a result
of this, the scientific literature available to
substantiate their use is increasing rapidly.
One natural therapeutic agent that is of
particular interest to wound care prac-
titioners is honey. It is currently enjoying
considerable success as a ‘new treatment’
for use in the management of a wide
Richard White is Senior Research Fellow, Department of
Tissue Viability, Grampian Acute Health Services, Aberdeen.
Richard White
“ These are products
that are obtained
from natural sources
for example: honey
which has been used
for many thousands
of years in both
topical and oral
presentations.”
variety of chronic and acute wounds.
Honey has been attributed with a num-
ber of beneficial properties of relevance
to wound healing, namely antibacterial,
debriding, malodour reducing, anti-
inflammatory and the ability to stimulate
healing. A variety of wounds show
beneficial effects from being treated with
honey or honey-based dressings, includ-
ing leg ulcers, pressure ulcers, burns,
meningococcal skin lesions, Fournier’s
gangrene and post-operative wounds.
The following articles present an
overview of the applications of natural
therapeutic agents and focus in particular
on honey as a treatment for chronic
and acute wounds. In Part I, the first in
a series of four articles provides an insight
into some of the natural products that
are used in wound care, including honey.
This is followed by a review of recent
clinical literature relating to the use
of honey in the treatment of a variety
of wounds.
EDITORIAL
Richard White
The third article presents a case for
honey-based products to be included
in wound care formularies. Honey is
important in the prevention and reduc-
tion of malodour in wounds, and the
fourth article reviews the basis for this.
Part II looks at the Mesitran range of
honey-based wound care products that
have recently been introduced into
the UK by Medlock Medical (Oldham,
UK). Later articles in this supplement
provide up-to-date information on
clinical case study data, demonstrating
the use of the Mesitran products in a
variety of wounds. A product focus and
supporting data relating to the physical
characteristics of the Mesitran dressings
provide information to aid the nurse
in identifying those indications for which
Mesitran products can be used.
Wounds UK 3
Clinical REVIEW

Natural Therapeutic Agents

for the Topical Management
of Wounds
The limitations of modern therapeutic agents and conventional dressings have led to a resurgence of interest in
using traditional remedies, including a number of naturally occurring agents, in managing wounds. Data published
from in vitro, animal and clinical evaluations provide rational explanations for the use of natural therapeutic agents
in the treatment of wounds. The currently available clinical evidence indicates that numerous agents are beneficial
to the wound healing process, without any significant concerns regarding their safety.

Keith Cutting RN MN MSc. Philip Davies BSc (Hons)

complementary and alternative therapies, their activity against bacteria by binding

KEY WORDS
Review Wound
Silver Zinc
Vitamins Cod Liver Oil
Lanolin Aloe vera
Calendula officinalis Honey
Sunflower Oil
Therapeutic agents derived from natural
sources have been utilised by civilisations
for thousands of years to treat and
prevent a wide variety of medical con-
ditions. In more recent times, naturally
occurring agents have been incorporated
into a number of conventional medical
products and pharmaceutical prepara-
tions. Despite the major advances that
have been made in the development
of synthetic agents for use in medicinal
products and medical devices, there
remains a substantial interest in the use
of natural medicines amongst health
professions and throughout the general
population. Furthermore, the use of
Keith Cutting RN MN MSc. Vascular Nurse Specialist, Ealing
Hospital NHS Trust, London and Principal Lecturer in Health
Studies BCUC; Philip Davies BSc (Hons), Medical Information
Manager, Medlock Medical Limited, Tubiton House, Medlock
Street, Oldham, OL1 3HS.
often derived from natural sources, is to negatively charged components
on the increase. in proteins and nucleic acids, thereby
altering the structure of bacterial cell
Wound management is just one of many walls, membranes and nucleic acids,
disciplines in which naturally occurring and thus affecting their viability
therapeutic agents have been, and (Cooper, 2004).
continue to be, evaluated and used by
health professionals because they are
believed to have properties that are
conducive to wound healing. One such
agent is honey, that has been used as a
topical wound treatment for thousands
of years (Dunford et al, 2000) and is
now increasingly being recognised by
those involved in wound management
as a viable alternative to conventional
dressings (White and Molan, 2005).
This article focuses on a number of
topically-applied, naturally occurring
agents that are believed to facilitate the
wound healing process and reviews the The major silver preparations that have
published data on which their perceived seen widespread clinical use during the
benefits can be evaluated. last century are silver nitrate solution,
silver sulphadiazine cream, and a variety
MINERALS of dressings containing elemental or
Silver ionised silver. Silver nitrate has a number
For centuries, silver has been used to of disadvantages, including: discomfort
treat wounds and ulcers (Klasen, 2000). on application (Lansdown, 2004), poor
Whereas metallic silver is relatively penetration of wound eschar, the need
unreactive, ionic silver is known to be for continuous occlusive dressings that
active against a wide range of micro- may affect the electrolyte and water
organisms at very low concentrations balance of patients, and black dis-
(Percival et al, 2005). Silver ions exert colouration of wounds and surrounding

4 Wounds UK

tissue (argyria) (Weber and Rutala, 2001).
Silver nitrate solution has also been
associated with methaemoglobinaemia
and metabolic disturbances (Morgan,
2004).
Since the introduction of silver sulpha-
diazine cream in the 1960s and the
subsequent availability of silver-containing
dressings, the use of silver nitrate has
declined. Silver sulphadiazine is now an
established treatment for burns (Cooper,
2004) although the emergence of
sulphadiazine-resistant bacteria has been
reported following the treatment of
extensive burns with silver sulphadiazine
(Lowbury et al,1976). Silver sulpha-
diazine has been shown to be effective
in the treatment of leg ulcers (Blair et
al, 1988; Bishop et al, 1992), fingertip
injuries (Buckley et al, 2000), and
infected wounds (O’Meara et al, 2001).
Silver-impregnated dressings have been
evaluated in numerous laboratory and
clinical studies (Lansdown, 2004). In the
treatment of partial-thickness burns,
leg ulcers and pressure ulcers, silver-
impregnated dressings have been
shown to increase epithelialisation and
granulation, and decrease wound size
(Wunderlich and Orfanos, 1991; Tebbe
and Orfanos, 1996; Caruso et al, 2004).
Studies have also shown that silver-
impregnated dressings are effective in
treating a variety of infected wounds
(acute and chronic) and preventing
recurrences (Bornier and Jeannin, 1989;
Verdu Soriano et al, 2004). Silver-
impregnated dressings are generally
regarded as safe for use in wound
management (Lansdown et al, 2005).
SILVER – Key Attributes
Antimicrobial
Zinc
Zinc is an essential element for growth
and development. Deficiency of zinc is
associated with a variety of disorders,
including impaired wound healing and
chronic skin ulceration (Phillips et al,
1977). Zinc, principally in the form of
zinc oxide or calamine, has been used in
the management of wounds for more
than 3000 years (Lansdown, 1996).
Bandages impregnated with pastes
containing zinc oxide are used in the
treatment of leg ulcers, often in
conjunction with compression therapy.
A stocking impregnated with a zinc
oxide-containing ointment is also
commercially available for use in the
management of leg ulcers.
Data from animal studies have revealed
that the topical application of zinc oxide
can reduce the inflammatory reaction
in granulation tissue and significantly
increase the re-epithelialisation of
wounds (Agren et al, 1993; Lansdown,
1993). Agren (1993) proposed that
zinc oxide promotes the breakdown
of collagen in necrotic tissue by
increasing the activity of metallopro-
teases. It has also been proposed that
the topical application of zinc oxide can
enhance the re-epithelialisation of
wounds by increasing the gene
expression of insulin-like growth factor-1
(IGF-1), thereby stimulating the mitotic
index of epidermal base cells (Tarnow
et al, 1994).
As well as its wound healing properties,
zinc oxide has been shown to have a
varying degree of antimicrobial activity.
In vitro studies have shown that Gram-
positive bacteria including Staphylococcus
aureus are susceptible to zinc oxide,
whereas Gram-negative aerobic bacteria
and streptococci are not (Soderberg et
al, 1990; Soderberg et al, 1991). It has
been proposed that zinc affects bacteria
by binding to the surface of bacteria,
thereby altering the structure and
function of their membranes (Soderberg
et al, 1990; Soderberg et al, 1991). It has
also been suggested that zinc oxide
protects cells by inhibiting bacterial
Clinical REVIEW
adhesion and internalisation (Roselli et
al, 2003).
Topical application of zinc oxide has been
shown to be effective in the manage-
ment of a variety of wound types,
including arterial and venous leg ulcers
(Stromberg and Agren, 1984; Stacey et
al,1997), pressure ulcers (Stromberg
and Agren, 1985), finger-tip and soft-
tissue injuries (Hughes and McLean,
1988), and diabetic foot ulcers (Apelqvist
et al, 1990). In general, topical applica-
tions of zinc compounds, in particular
zinc oxide, are associated with very few
adverse events. Zinc oxide has a very
long history of use within wound care
and reports of irritancy are scarce
(Lansdown, 1990).
ZINC – Key Attributes
Anti-inflammatory
Antimicrobial
Breaks down collagen in
necrotic tissue
Stimulates re-epithelialisation
VITAMINS
It is believed that the topical application
of certain vitamins can assist in the wound
healing process.
Vitamin A
Vitamin A (retinol) plays a key role in the
development of epithelial and bone
tissue, cellular differentiation, and the
functioning of the immune system.
Wounds UK 5
Clinical REVIEW
The results of studies carried out on
experimental wounds suggest that
vitamin A can enhance the early
inflammatory phase of the healing
process (by increasing macrophage
availability at the wound site), modulate
collagenase activity, promote epithelial
cell differentiation, improve the
localisation and stimulation of the
immune response, and increase both
collagen cross-linkage and wound-
breaking strength (Seifter et al, 1975;
Demetriou et al, 1984; Levenson et al,
1984; Hunt, 1986; Greenwald et al,
1990).
VITAMIN A – Key Attributes
Enhances early inflammatory
phase of wound healing
Modulates collagenase activity
Promotes differentiation of
epithelial cells
Immunostimulatory
Increases collagen cross-linkage
and breaking strengths of wounds
Vitamin C
Vitamin C (ascorbic acid) is an essential
cofactor for the synthesis of collagen in
skin and connective tissue and con-
tributes to the tensile strength of collagen
(Dickerson, 1993). It has also been
shown to increase neutrophil function
(Goetzl et al, 1974), promote angio-
genesis (Nicosia et al, 1991), and to have
antioxidant properties (Frei et al, 1988).
6 Wounds UK
Laboratory research has demonstrated
that vitamin C has antimicrobial
properties, active against numerous
species including Staphylococcal species
(including Staphylococcus aureus),
Streptococcal species, Proteus vulgaris,
Escherichia coli, Bacillus subtilis, and
Candida albicans (Myrvik and Volk,
1954; Stacpoole, 1975; Rawal, 1978).
VITAMIN C – Key Attributes
Cofactor for collagen synthesis
Increases neutrophil function
Promotes angiogenesis
Antioxidant
Antimicrobial
Vitamin E
Consisting of two classes of related
compounds, the tocopherols and the
tocotrienols (Musalmah et al, 2002),
vitamin E is regarded as the major lipid-
soluble antioxidant in skin.
It is known to play a role in preventing
peroxidation of lipids, thereby
contributing to the stability of cell
membranes (Havlik et al, 1997).
Although the perceived wound healing
properties of vitamin E have not been
demonstrated in the clinical setting, a
number of studies on animal wounds
have demonstrated that it can have a
positive effect on the healing process
(Ehrlich et al, 1972) and help to modify
undesirable scar formation (Jurkiewicz et
al, 1995; Palmieri et al, 1995). It has
also been reported that vitamin E has
anti-inflammatory and immuno-
stimulatory properties (Leach, 2004).
VITAMIN E – Key Attributes
Antioxidant
Anti-inflammatory
Immunostimulatory
Topical applications of vitamins A,C and
E are generally well-tolerated and are
highly unlikely to be associated with any
serious adverse effects.
ANIMAL-DERIVED PRODUCTS
Cod Liver Oil
Cod liver oil is the purified fatty oil
obtained from the fresh livers of Gadus
morhua (Atlantic cod) and other species
of the Gadidae family of fish. It is a rich
source of vitamin D3 (cholecalciferol),
a good source of vitamin A (retinol), and
also contains several polyunsaturated
fatty acids (Terkelsen et al, 2000).
It is believed that the vitamin A and the
polyunsaturated fatty acid content
of cod liver oil contribute to its wound
healing properties. In addition to the
wound healing properties of vitamin A
described earlier, it has been suggested
that eicosapentaenoic acid, one of the
polyunsaturated fatty acids in cod liver
oil, contributes to its wound healing
properties. As eicosapentaenoic acid is
the starting point for the formation
of prostaglandin 3 and thrombexane 3,
both of which have anti-aggregatory
effects on platelets and vasodilatory

properties, it has been postulated that
the topical application of cod liver oil to
wounds can increase the levels of growth
factors, cytokines, immunoglobulins,
and oxygen in wound tissues, thereby
accelerating the healing process
(Terkelsen et al, 2000).
There are numerous reports of the
successful treatment of wounds with cod
liver oil (Brandaleone,1933; Dalldorf,
1938; Aldrich, 1942; Hardin, 1942;
Doughtry, 1945; Behrman et al, 1949;
Grayzel and Schapiro, 1956). In the
randomised trial carried out by Grayzel
and Schapiro (1956), the topical
application of cod liver oil was shown
to promote healing, in addition to
protecting wounds from further
mechanical and chemical injury, and
bacterial contamination.
There would appear to be no reports of
serious adverse effects associated with
the topical application of cod liver oil.
COD LIVER OIL –
Key Attributes
Increases levels of growth factors,
cytokines, immunoglobulins and
oxygen levels in wound tissue
Plus attributes of vitamin A
Lanolin
Consisting of a mixture of higher fatty
acids esterified with monohydric alcohols
comprising cholesterol esters and related
alcohols, lanolin is a purified anhydrous
waxy substance obtained from the
wool of sheep (Wolf, 1996).
Lanolin has been used for thousands
of years, principally for its emollient
properties in managing dry skin
conditions. Lanolin and lanolin derivatives
are included in a large number of
emollient preparations as they form lipid
films on the skin surface which help
to restore the epidermal barrier and
reduce water loss. In addition to its
occlusive properties, lanolin can
penetrate the skin and enter the inter-
cellular spaces, where it forms an
emulsion with the epidermal water
(Clark and Steel, 1993), thereby
retaining water and releasing it into the
dry stratum corneum when required
(Stone, 2000). Its barrier and hydrating
properties also make lanolin a suitable
vehicle for retaining water-soluble
pharmaceutical and cosmetic agents
(Hanna et al, 1973). In a study on
experimental wounds, it was demon-
strated that lanolin can increase the
rate of healing (Chvapil et al, 1988).
The authors of the study offered three
possible explanations for their
observations: lanolin retains moisture at
the wound surface, thereby providing
the moist environment conducive to
healing; the cholesterol esters in lanolin
have a direct effect on cell mitosis;
and lanolin indirectly stimulates the
inflammatory response.
In the clinical setting, the evaluation of
lanolin as a topical agent for wound care
has been restricted to the treatment
of sore and cracked nipples. The results
of a number of studies demonstrate
that lanolin is an effective and well-
tolerated topical agent for the treatment
and prevention of cracked and sore
nipples (Spangler and Hildebrandt,
Clinical REVIEW
1993; Brent et al, 1998; Huml, 1999;
Tanchev et al, 2004).
In recent times, lanolin has developed an
ill-deserved reputation as an important
sensitiser. It has been suggested,
however, that misleadingly high
proportions of positive patch tests to
lanolin have arisen partly because of
selection of groups of patients who are
particularly vulnerable to irritant
reactions which are misinterpreted as
allergy. In reality, sensitisation to lanolin
in the general population remains rare,
of the order of one in a million (Kligman,
1998). Furthermore, ultra-purified
medical grade lanolin has been shown
to cause almost zero sensitisation
(Stone, 2000).
LANOLIN – Key Attributes
Emollient
Stimulates healing
HERBAL EXTRACTS
Aloe vera
Aloe vera (synonym: Aloe barbadensis)
is a cactus-like plant that grows readily
in hot, dry climates.
The Aloe vera plant is made up of
between 99 and 99.5% water, with
the remaining solid material containing
over 75 different ingredients, including
vitamins, minerals, enzymes, sugars,
anthraquinones, lignin, saponins,
sterols, salicylic acids, and amino acids
(Atherton, 1998). The gel, extracted
from the mucilaginous cells in the
centre of the leaves, is the
component of the Aloe vera plant that
is most widely used in cosmetic and
medical products intended for topical
use (Vogler and Ernst, 1999).
Wounds UK 7
Clinical REVIEW
Aloe vera has been used for thousands
of years as a medicinal herb for a
multitude of purposes, including the
treatment of wounds (Clark, 2002). It
is believed that the reported beneficial
effects of Aloe vera in wound manage-
ment are due to the actions of a number
of its constituents. A glycoprotein fraction,
named G1G1M1D12, isolated from
Aloe vera has been shown to be able
to stimulate wound healing via cell
proliferation and migration (Choi et al,
2001). Oligosaccharides within Aloe
vera have been shown to have anti-
inflammatory activity (Byeon et al, 1998;
Davis et al, 1994). It has also been
proposed that Aloe vera has analgesic
properties, probably due to a protease
inhibitor within it interfering with the
action of bradykinin, the substance
responsible for pain at the site of acute
inflammation. The same protease
inhibitor has also been shown to cause
vasoconstriction, decreasing the swelling
and redness in inflammation (Natow,
1986). Laboratory studies have indicated
that Aloe vera has significant antibacterial
and antifungal activities (Lorenzetti et al,
1964; Fujita et al, 1978; Mohamed et al,
1999).
A number of studies involving experi-
mental wounds have demonstrated that
topical applications of Aloe vera can
improve healing, as well as reducing
inflammation, pain and oedema (Davis
et al,1987; Davis et al, 1988; Davis et
al, 1989; Davis and Maro, 1989; Davis
et al, 1994a; Chithra et al, 1998;
Somboonwong et al, 2000).
In a clinical study involving 27 patients
with partial-thickness burns, Aloe vera
gel was associated with faster healing
than Vaseline gauze. Histological
examinations demonstrated that Aloe
vera gel stimulated the rapid growth of
squamous epithelium and reformed
dermal fibro-vascular and collagen
tissue. It was also observed that the
inflammatory cell infiltration was less in
the wounds treated with Aloe vera
gel. The Aloe vera treatment was not
associated with any allergic reactions or
dermatitis, although some discomfort
and transient pain was reported
(Visuthikosol et al, 1995).
8 Wounds UK
In a pilot study involving seven patients
with chronic leg ulcers, a combination
of oral and topical Aloe vera was
evaluated. Three of the wounds healed
completely, two healed partially and
one showed no improvement. One
patient was unable to tolerate the
stinging sensation caused by the topically
applied Aloe vera and thus withdrew
from the study. The other patients found
the regime very acceptable. The Aloe
vera treatment was reported to have a
notable cleansing effect, resulting in less
exudate and malodour, and a reduction
in wound bacteria (Atherton, 1998).
ALOE VERA – Key Attributes
Stimulates wound healing (cell
proliferation and migration)
Anti-inflammatory
Analgesic
Antimicrobial
Calendula Officinalis
The flowers of the Calendula officinalis
(Marigold) plant contain flavonoids,
terpenoids, volatile oils and a variety of
other chemically active constituents
(Newall et al,1996). Calendula officinalis
has been used topically since ancient
times for treating wounds.
It has been reported that Calendula
officinalis possesses anti-inflammatory,
antimicrobial and wound healing
properties. The anti-inflammatory effects
of Calendula officinalis have been
attributed to its triterpene constituents
(Graf, 2000).
The results of studies on experimental
wounds suggests that Calendula
officinalis promotes healing by
stimulating granulation and increasing
glycoproteins, nucleoproteins and
collagen proteins at wound sites (Patrick
et al, 1996; Brown and Dattner, 1998).
In vitro studies have shown that
Calendula officinalis has notable anti-
bacterial (Iauk et al, 2003) and antiviral
(Kalvatchev et al, 1997) activities.
The beneficial effects of Calendula
officinalis on wounds has been demon-
strated in a number of clinical evaluations.
Kartikeyan et al (1990) describe the
results of a study in which a 30- 40%
reduction in the depth and diameter of
trophic ulcers and a complete absence
of secondary infection were achieved
with four weeks of treatment with
calendula ointment. Lavagna et al (2001)
report on a study in which the size of
surgical wounds following Caesarean
sections were significantly reduced
following the topical administration of
a mixture of Calendula and Hypericum
oils. In a randomised study comparing
Calendula ointment, a proteolytic
ointment and Vaseline for the manage-
ment of second and third degree burns
carried out by Lievre et al (1992),
Calendula performed better than
Vaseline in terms of healing and grafting
time. It was also shown to be better
tolerated than the other two treatments.
Although allergic contact dermatitis is
considered to be the main adverse
effect of Calendula officinalis, serious
adverse effects have yet to be reported
and it is generally considered to be
safe (Bedi and Shenefelt, 2002).
CALENDULA OFFICINALIS –
Key Attributes
Promotes wound healing
(stimulates granulation;
increases glycoproteins,
nucleoproteins and collagen
proteins in wound)
Anti-inflammatory
Antimicrobial

Sunflower oil
Described as the refined fatty oil obtained
from the seeds of Helianthus annuus,
sunflower oil (also known as sunflower
seed oil) contains a variety of fatty acids,
including a high concentration (66%)
of the essential fatty acid, linoleic acid
(Rowe et al, 2003).
The essential fatty acids are thought to
contribute to the wound healing prop-
erties of sunflower oil in a number of
ways. It is believed that they help to
maintain the epidermal integrity and
barrier properties of the skin. The lipid
components of cell membranes are
known to include some of the essential
fatty acids found in sunflower oil.
A deficiency in essential fatty acids can
impair wound healing (Sholar and
Stadelmann, 2003). Essential fatty acids
are known to be the metabolic
precursors of the prostaglandins that
play a central role in the inflammatory
response, regulating cell division and
epidermal differentiation (Greeves,
1972; Eaglstein and Weinstein, 1974;
Glasgow and Eling, 1990). Linoleic acid
is known to be a powerful pro-
inflammatory mediator, causing the
migration of granulocytes and macro-
phages, and it has been suggested that
it can stimulate cell growth by regulating
biochemical events that precede fibro-
blastic mitogenesis (Glasgow and Eling,
1990). More recently, it has been
proposed that the essential fatty acids
generate other lipoid mediators such
as intermediate hydroperoxides with
anti-inflammatory activities and lipoxins
with immunomodulatory effects
(Cardoso et al, 2004).
Clinical studies and investigations carried
out on experimental wounds have
shown that topically applied sunflower
oil can effectively reverse essential fatty
acid deficiency (Prottey et al, 1974;
Friedman et al, 1976; Skolnik et al, 1977),
help to prevent nosocomial infections
(Darmstadt et al, 2004; Darmstadt et al,
2005) and pressure ulcers (Gosnell,
1973; Declair, 1997), and enhance the
formation of granulation tissue (Marques
et al, 2004), thereby enhancing the
epithelial resurfacing of wounds.The
work undertaken to date has not
identified any serious adverse effects
of topically applied sunflower oil.
SUNFLOWER OIL –
Key Attributes
Stimulates cell growth
Anti-inflammatory
Antimicrobial
Honey
Honey is a solution typically containing
approximately 17% water and 80%
sugars, with fructose and glucose being
the predominant sugars. Other carbo-
hydrates, proteins (including enzymes),
vitamins and minerals are also found in
honey (Molan, 2005). Honey is reported
to have antimicrobial and anti-
inflammatory properties, and to be
capable of promoting wound debride-
ment, maintaining a moist wound
environment, stimulating healing, and
deodorising wounds (White and Molan,
2005).
Clinical REVIEW
Laboratory studies have demonstrated
that honey has a broad antimicrobial
spectrum, including activity against the
common wound pathogens and
antibiotic-resistant strains such as
methicillin-resistant Staphylococcus
aureus (MRSA) and vancomycin-
resistant enterococci (VRE) (Cooper,
2005). Honey’s antimicrobial action is
believed to be due to a number of
factors, including: (i) the binding of water
molecules to the sugars within honey,
thereby making them unavailable to
microorganisms; (ii) the acidity of honey;
(iii) the ability of honey to produce low
levels of an antiseptic (hydrogen
peroxide) when diluted, and (iv) the
presence of antimicrobial chemicals
within honey (Molan, 2005).
In addition to the direct antimicrobial
effect that honey has on the bacteria that
cause wound malodour, it is believed
that, in the presence of honey, bacteria
would metabolise glucose in preference
to the amino acids in the decomposed
serum and tissue proteins that they
would normally utilise. Whereas the
breakdown products of the amino acids
are malodorous, glucose is metabolised
to non-malodorous compounds (White
and Molan, 2005).
The topical application of honey to
wounds is known to facilitate good
wound bed preparation through the
promotion of autolytic debridement.
The high osmolarity of honey (due to
its high sugar content) draws out lymph
fluid from beneath the wound tissue,
thereby providing a good supply of
protease enzymes at the interface
between the wound bed and the over-
lying slough and necrotic tissue
(Molan, 2005).
Health professionals currently have
access to a range of honey-based wound
care products in ointment, gel and
dressing formats. A substantial number
of clinical evaluations, including a series
of randomised controlled trials, have
shown that honey has successfully
treated a wide range of wound types
including some that have failed to
respond to management with conven-
tional dressings.
Wounds UK 9
Clinical REVIEW
These include: minor lesions
(abrasions, cuts, cracked nipples);
infected wounds (traumatic, surgical);
burns; Fournier’s gangrene; skin lesions
associated with meningococcal
septicaemia; abscesses; cancrum oris;
large septic wounds; pressure ulcers;
skin ulcers (leg ulcers, varicose ulcers,
diabetic ulcers, tropical ulcers, foot ulcers
in lepers, sickle cell ulcers, malignant
ulcers); and infected donor sites from
split-thickness skin grafting, without
causing any adverse effect on wound
tissues (Molan, 2005). In the treatment
of partial-thickness burns, honey has
been shown to be superior to both silver
sulphadiazine (Subrahmanyam, 1991;
Subrahmanyam, 1998) and a polyur-
ethane film dressing (Subrahmanyam,
1993). Honey has also been shown to
be superior to topical antiseptics in the
management of post-operative wound
infections (Al-Waili and Saloom (1999).
Allergy to honey is reported to be rare
(Kristala et al, 1995). Other than the
occasional report of minor discomfort
(sometimes described as a ‘drawing
sensation’), the use of honey is highly
unlikely to result in any undesirable
effects (Molan, 1999; Molan, 2001).
HONEY – Key Attributes
Antimicrobial
Anti-inflammatory
Promotes wound
debridement
Maintains moist wound
environment
Stimulates healing
Deodorises wounds
Conclusion
There is a growing body of scientific and
clinical data on which the potential
benefits of topically-applied, naturally
occurring therapeutic agents to wounds
can be evaluated. In the case of some
agents, for example honey, it could be
argued that there is more evidence of
their safety and efficacy in the published
literature than for some of the more
10 Wounds UK
conventional wound care products that
are currently employed by health pro-
fessionals. Although there is insufficient
published data to fully elucidate the
mechanisms of action and clinical
benefits of a number of naturally occur-
ring agents, the currently available
literature would generally support their
continued use and evaluation in the
wound care setting.
Key Points
Naturally occurring agents have
been used in the field of wound
care for centuries
There has recently been a
resurgence of interest in using
natural remedies for managing
difficult-to-heal wounds
Data generated from laboratory,
animal and clinical studies support
the inclusion of natural therapeutic
agents in wound dressings and
preparations
Further research is required to
fully understand the mechanisms
by which some natural
therapeutic agents affect the
wound healing process
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Wounds UK 13
Clinical REVIEW

Recent Clinical Usage of

Honey in the Treatment
of Wounds
There has recently been a substantial resurgence in the use of honey for the topical treatment of wounds.
This review was carried out to establish the level of clinical evidence that exists to demonstrate the
therapeutic properties of honey and to support the use of honey-based products in the management of
wounds. The vast majority of the published articles describing the use of honey in wound management
demonstrate its efficacy, cost-effectiveness, and excellent record of safety.
The literature includes reports of studies in which honey has been demonstrated to be superior to
a number of traditional dressings. The published results of numerous clinical evaluations on honey provide
evidence of its ability to promote autolytic debridement, maintain a moist wound environment, protect
wounds from bacterial growth and cross-infection, and deodorise wounds, without causing any adverse
effect on wound tissues. There is substantial evidence of honey being used successfully on a wide range
of wound types.

Philip Davies BSc (Hons)

documented by the ancient Egyptians

KEY WORDS
Honey
Wound
Dressings
Review
The history of honey as a medicine is
a fascinating and ancient one. Stone
paintings suggest that honey has been
used by humans for at least 6,000 years
and references to the use of honey as
a medicine can be found in ancient
scrolls, tablets and books. Honey is
probably the most ancient wound
dressing known. Reports indicate that
the use of honey has been a valued
part of wound management for many
centuries. The use of honey in the
management of wounds was first
Philip Davies BSc (Hons), Medical Information Manager,
Medlock Medical Limited, Tubiton House, Medlock Street,
Oldham, OL1 3HS
4000 years ago (Dunford et al, 2000). Table 1
It has been reported that the Ancient Typical composition of honey
Greeks, Romans and Chinese used (National Honey Board, 2005)
honey as a topical antisepsis for sores,
wounds and skin ulcers (Jones, 2001). Component %
There is also evidence that, during Water 17.1
World War I, Russian soldiers used Fructose 38.5
honey to prevent wound infections and Glucose 31.0
to accelerate healing (National Honey
Board, 2005). Maltose 7.2
Sucrose 1.5
Honey is the substance made when the Other carbohydrates 4.0
nectar and sweet deposits from plants Proteins trace
are gathered, modified and stored in
Vitamins trace
the honeycomb by honey bees. It is a
supersaturated sugar solution with Minerals trace
approximately 17% water. Fructose is
the predominant sugar, followed by anisms of action and therapeutic uses,
glucose. As well as sugars and other there has recently been a substantial
carbohydrates, honey contains small resurgence in the use of honey for the
amounts of proteins (including enzymes), topical treatment of wounds, particularly
vitamins and minerals (Table 1). Based where conventional modern therapeutic
on steadily accumulating clinical and agents are deemed to have failed (Lusby
scientific data relating to its mech- et al, 2002; White and Molan, 2005).

14 Wounds UK

Honey has antimicrobial and anti-
inflammatory properties, it promotes
debridement, maintains a moist
wound environment, stimulates
healing, and deodorises wounds
without causing any adverse effect on
wound tissues (Table 2).
Antimicrobial activity
The antimicrobial properties of honey
are related to its high osmolarity, its
ability to generate hydrogen peroxide
when diluted, its acidity, its ability to
limit the availability of water, and the
direct action of antimicrobial chemicals
present within it. All micro-organisms
require supplies of nutrients. Any
restriction in the supply or availability of
carbon, nitrogen, minerals and water is
likely to compromise their metabolism
of microorganisms. Honey is a super-
saturated solution of sugars with low
water content. The binding of water
molecules to the sugars makes them
unavailable for micro-organisms. The
acidity of honey (pH 3.4 – 6.1) also
helps to restrict microbial growth
(Cooper, 2005).
When honey is diluted (for example,
by wound exudate), an enzyme
(glucose oxidase) is activated to
produce low levels of hydrogen
peroxide, a well-known antimicrobial
agent. Historically, preparations
containing hydrogen peroxide (often
as 3% solutions) have been used as
topical wound antiseptics although
they are no longer considered
suitable because of their inflammatory
effects on wound tissue. The typical
concentrations of hydrogen peroxide
that accumulate in honey are
reported to be approximately 1000
times lower than that associated with
the 3% hydrogen peroxide solutions,
hence the levels of hydrogen
peroxide found in honey are deemed
to be non-toxic (Dunford et al, 2000a).
Anti-inflammatory activity
It is believed that the ability of honey
to clear infection and debride wounds
contributes to its anti-inflammatory
action. The main mechanism by which
it reduces excessive inflammation is
yet to be discovered although it has
Clinical REVIEW
Table 2
Key attributes of honey
Antimicrobial
Active against a wide range of wound pathogens, including methicillin-
resistant Staphylococcus aureus (Dixon, 2003; Vandeputte and Van
Waeyenberge, 2003; Cooper, 2005)
Protects wounds from bacterial growth and cross-infection (Molan, 2005)
Anti-inflammatory
Reduces the inflammation associated with wounds (Subrahmanyam, 1998;
Stephen-Haynes, 2005)
Promotes debridement
Facilitates the removal of slough and necrotic tissue (Vandeputte and Van
Waeyenberge, 2003; White and Molan, 2005)
Maintains a moist wound environment
Provides optimum conditions for growth of cells involved in the repair process
(Molan, 2005)
Stimulates healing
Promotes healing, even in dormant wounds, by growth of new tissues,
including epithelium (Subrahmanyam, 1998; White and Molan, 2005)
Deodorises wounds
Reduces wound malodour, thereby improving patient quality of life (Dunford et
al, 2000, Stephen-Haynes, 2005)
been suggested that it may be linked from some other dressings in that
to the antioxidants in honey mopping they promote a moist wound healing
up free radicals (Molan, 2005). environment without encouraging
microbial growth and maceration
Debriding action of the surrounding skin; factors that
Honey promotes the debridement of can delay the healing process.
wounds by the autolytic action of The antimicrobial activity of honey
tissue proteases. As a result of its high helps to prevent the risk of microbial
osmolarity, honey can draw out lymph growth while its osmotic action will
fluid from the underlying circulation tend to draw fluid out from the skin
through wound tissue, thereby rather than let it soak in. Dehydration
providing a constant replenished of wound tissue is prevented by the
supply of proteases at the interface of underlying circulation replacing fluid
the wound bed and the overlying lost from the wound (Molan, 2005).
sloughy and necrotic tissue. The
osmotic action of honey also washes If honey is used in combination with
the surface of the wound bed from a secondary dressing, then the
beneath (White and Molan, 2005). drawing of fluid from the underlying
circulation can create a film of diluted
Maintenance of moist wound environment honey under the dressing, thereby
Like most modern dressings, honey helping to prevent it from adhering
dressings provide a moist environment to the wound bed and facilitating
that is conducive to wound healing. non-traumatic dressing changes
However, honey dressings do differ (Molan, 2005).
Wounds UK 15
Clinical REVIEW

Stimulation of healing Aim sites (Table 3) were supplemented

It is reported that honey can stimulate
wound healing in a number of different
ways. Data obtained from research
undertaken on experimental wounds
suggest that honey can stimulate
angiogenesis (Gupta et al, 1992; Kumar
et al, 1993) and the synthesis of collagen
and other connective tissue components
(Suguna et al, 1992; Suguna et al, 1993).
It has also been suggested that the
application of honey to wounds can
promote healing by providing the
traumatised tissue with a topical supply
of nutrients which would be augmented
by the nutrients that are present within
the lymph fluid being drawn from the
underlying circulation (Molan, 2005).
Reduction of wound malodour
Wound malodour is caused by anaerobic
bacterial species (such as Bacteroides
spp, Peptostreptococci and Prevotella
spp) that produce malodorous com-
pounds such as ammonia, amines and
sulphur compounds, formed by the
metabolism of amino acids from
decomposed serum and tissue proteins
(Bowler et al, 2001). As well as having
a direct antimicrobial effect on the
bacteria that cause wound malodour, it
has been suggested that honey provides
a rich source of glucose that would be
metabolised by bacteria in preference to
amino acids, resulting in the production
of the non-malodorous metabolite,
lactic acid (White and Molan, 2005).
The aim of this review is to establish the with manual searches of conference
level of clinical evidence that exists to proceedings and journals of relevance
demonstrate the reported therapeutic to wound management.
properties of honey and to support the
use of honey-based products in the Results
management of wounds. The literature search identified a
significant number of published clinical
Methods evaluations of honey and honey-based
An extensive literature search was products in the treatment of surgical and
undertaken to identify published reports trauma wounds, burns, pressure sores,
of clinical evaluations (randomised leg ulcers, diabetic ulcers, split-thickness
controlled trials, non-randomised trials, skin graft donor sites, skin lesions from
and case reports) of honey and honey- meningococcal septicaemia, Fournier’s
based preparations for treating wounds gangrene and necrotising fasciitis. These
(acute and chronic). The search was include six randomised controlled trials
restricted to evaluations that were (Tables 4 and 5) and 19 other clinical
published between January 1990 and evaluations (non-randomised studies,
July 2005. Electronic searches of uncontrolled studies, open studies and
bibliographic databases and internet case reports). (Tables 6-10).
Table 3
Electronic data sources
Bibliographic databases
MEDLINE (National Library of Medicine, Bethesda, USA)
EMBASE (Elsevier BV, Amsterdam, Netherlands)
CINAHL (Cinahl Information Systems, Glendale, USA)
AMED (British Library, London, UK)
Internet sites
Cochrane Library
World Wide Wounds

Table 4
Randomised controlled trials – surgical wounds
Al Waili & Saloom (1999) Honey (n=26) vs topical antiseptics (n=24) on post-operative wound infections
(all patients received systemic antibiotics).
Time to eradication of bacterial infection (days): 6 ± 1.9 (honey) vs 14.8 ± 4.2
(topical antiseptics) (p < 0.05).
Period of antibiotic use (days): 6.88 ± 1.7 (honey) vs 15.45 ± 4.37
(topical antiseptics) (p < 0.05).
Complete wound healing (days): 10.73 ± 2.5 (honey) vs 22.04 ± 7.33
(topical antiseptics) (p < 0.05).
Size of post-operative scar (mm): 3.62 ± 1.4 (honey) vs 8.62 ± 3.8
(topical antiseptics) (p < 0.05).
Hospital stay (days): 9.36 ± 1.8 (honey) versus 19.91 ± 7.35
(topical antiseptics) (p < 0.05).

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 Clinical REVIEW

Table 5
Randomised controlled trials – burns
Subrahmanyam (1991) Honey-impregnated gauze (n=52) versus silver sulphadiazine-impregnated gauze (SSD)
(n=52) on partial-thickness burns.
Proportion of burns healed within 15 days: 87% (honey gauze) vs 10% (SSD gauze)
(p < 0.001).
Proportion of burns rendered sterile within 7 days: 91% (honey gauze) vs 7%
(SSD gauze) (p < 0.001).

Subrahmanyam (1993) Honey-impregnated gauze (n=46) vs polyurethane film dressing (n=46) on

partial-thickness burns.
Mean time to healing (days): 10.8 (honey-gauze) vs 15.3 (polyurethane film dressing)
(p < 0.001).

Subrahmanyam (1994) Honey-impregnated gauze (n=40) vs amniotic membrane dressing (n=24) on

partial-thickness burns.
Mean time to healing (days): 9.4 days (honey gauze) vs 17.5 (amniotic membrane)
(p < 0.001).
Proportion of patients with residual scars: 8% (honey gauze) vs 16.6%
(amniotic membrane) (p < 0.001).

Subrahmanyam (1996) Honey-impregnated gauze (n=50) vs boiled potato peel dressing (n=50) on
partial-thickness burns.
Proportion of burns healed within 15 days: 100% (honey gauze) vs 50%
(boiled potato peel).
Clearance of bacteria: 90% of burns treated with the honey dressing rendered sterile
within 7 days compared with persistent infection in burns treated with the boiled
potato peel dressing.

Subrahmanyam (1998) Honey (n=25) vs SSD-impregnated gauze (n=25) on partial-thickness burns.

Proportion of burns healed within 21 days: 100% (honey) vs 84% (SSD gauze)
(p < 0.001).
Proportion of burns showing histopathological evidence of reparative activity by day 7:
80% (honey) versus 52% (SSD gauze) (p < 0.005).
Clearance of bacteria: in 23/25 burns treated with honey that had positive swab cultures
at start of study, 15 (65%) became sterile in 7 days and 22 (96%) in 21 days; in 22/25
burns treated with SSD gauze with positive cultures, 16 (73%) became sterile in 7 days
and 19 (86%) in 21 days (p < 0.001).

Subrahmanyam (1999) Early tangential excision (TE) and skin grafting (n=25) vs honey-impregnated gauze dressing
(n=25) on moderate burns where half of the total burn area was full- thickness.
Skin grafting take rate: 99 ± 3% (TE group) vs 74 ± 18% (honey group) (p < 0.01).
Mean percentage of blood volume replaced: 35 ± 12% (TE group) vs 21 ± 15%,
(honey group) (p < 0.01).
Proportion of positive swab cultures: 10% (TE group) vs 30% (honey group) (p <0.05).

Wounds UK 17
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Clinical REVIEW
Table 6
Other clinical evaluations – surgical wounds
Phuapradit and Saropala (1992)
Ndayisaba et al (1993)
Vardi et al (1998)
Cooper et al (2001)
Ahmed et al (2003)
Table 7
Other clinical evaluations – trauma wounds
Ndayisaba et al (1993)
Wood et al (1997)
Ahmed et al (2003)
Vandeputte and Van
Waeyenberge (2003)
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Honey and approximation by micropore tape (n=15) vs traditional regime (cleansing
with hydrogen peroxide solution, Dakin’s solution, packing with saline-soaked gauze,
subsequent re-suturing) (n=19) in dehisced abdominal wounds following
Caesarean section (retrospective comparison). Mean length of stay in hospital (days):
4.5 (range 2-7) (honey group) vs 11.5 (range 9-18) (traditional regime).
Range of wound types (n=40) including surgical wounds treated with honey,
resulting in healing in 88% of cases.
Large, open, infected wounds (infants) that had failed to heal with conventional
treatment treated with honey (n=9). All wounds closed, clean and sterile after 21
days of treatment.
Recalcitrant wound treated with honey dressings. Recurrent infections ceased and
healing achieved within 4 months.
Series of wounds (n=60) including complicated surgical wounds (n=23) treated
with a honey dressing. In all but one patient, honey dressing found to be easy to
apply and helpful in cleaning the wounds.
Range of wound types (n=40) including surgical wounds treated with
honey, resulting in healing in 88% of cases.
Ulcers of various aetiologies, including a traumatic wound (n=1), with a mean
duration of 1 year treated with honey. Other wound types treated: varicose (n=7),
neuropathic (n=2) and arterial (n=1) ulcers. Significant healing (> 25% surface area)
in four ulcers, no change in six, and an increase in size of one wound reported.
Series of wounds (n=60) including acute traumatic wounds (n = 23) treated with a
honey dressing. In all but one patient, honey dressing found to be easy to apply and
helpful in cleaning the wounds.
In a series of 89 photo-documented case reports, wounds of various aetiologies,
including skin tears (n=8), treated with honey-based ointment. Other wound types
treated: pressure ulcers (n=18), diabetic ulcers (n=6), burns (n=7), venous ulcers
(n=36), and mixed pathology (n=14). Honey-based ointment reported to have very
quick debriding and antibacterial activity.
 Clinical REVIEW

Table 8
Other clinical evaluations – burns

Ndayisaba et al (1993) Range of wound types (n=40), treated with honey resulted in healing in 88% of cases.

Ahmed et al (2003) Series of wounds (n=60) including burns (n=9) treated with a honey dressing. In all but one
patient, honey dressing found to be easy to apply and helpful in cleaning the wounds.

Vandeputte and Van In a series of 89 photo-documented case reports, wounds of various aetiologies, including
Waeyenberge (2003) burns (n=7), treated with honey-based ointment. Other wound types treated: pressure
ulcers (n=18), diabetic ulcers (n=6), skin tears (n=8), venous ulcers (n=36), and mixed
pathology (n=14). Honey-based ointment reported to have very quick debriding and
antibacterial activity.

Table 9
Other clinical evaluations – leg ulcers/pressure ulcers/diabetic ulcers

Wood et al (1997) Ulcers of various aetiologies, including varicose (n=7), neuropathic (n=2) and arterial
(n=1) ulcers, with a mean duration of 1 year treated with honey. Other wound type
treated: traumatic wound (n=1). Significant healing (> 25% surface area) in four ulcers,
no change in six, and an increase in size of one wound reported.

Natarajan et al (2001) Leg ulcer infected with methicillin-resistant Staphylococcus aureus

treated with honey. Infection was eradicated from the ulcer and rapid healing achieved.

Alcaraz and Kelly (2002) Venous leg ulcer treated with a honey-based dressing. An improvement
in the wound was reported.

Ahmed et al (2003) Series of wounds (n=60) including pressure sores (n = 2) treated with a honey dressing.
In all but one patient, honey dressing found to be easy to apply and helpful in cleaning
the wounds.

Vandeputte and Van
Waeyenberge (2003)
In a series of 89 photo-documented case reports, wounds of various aetiologies, including
venous ulcers (n=36), pressure ulcers (n=18) and diabetic ulcers (n=6), treated with
honey-based ointment. Other wound types treated: skin tears (n=8), burns (n=7), and
mixed pathology (n=14). Honey-based ointment reported to
have very quick debriding and antibacterial activity.

Van der Weyden (2003) Pressure sores (n=2) treated with honey alginate dressing, resulting in rapid and complete
healing of both wounds. Reductions in wound odour and pain were also reported.

Dunford and Hanano (2004) Honey dressings applied to leg ulcers that had not responded to
12-weeks of compression therapy (n=40). Ulcer pain and size
decreased significantly and odorous wounds were deodorised promptly.

Robson (2004) Leg ulcers (n=2) successfully treated with standardised medical honey.

Wounds UK 19
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Table 10
Other clinical evaluations – miscellaneous

Efem (1993) Systemic antibiotics plus topical honey (n=20) versus orthodox treatment (surgical incision,
drainage, debridement, excision, secondary suturing, systemic antibiotics) (n=21) for Fournier’s
gangrene. Average duration of hospitalization: 4.5 weeks versus 4 weeks, respectively. Number
of deaths: 0 versus 3, respectively. Response to treatment and alleviation of morbidity were
faster in honey group and obviated the need for anaesthesia and surgery.

Hejase et al (1996) Thirty-eight patients with Fournier’s gangrene were treated with broad-spectrum triple
antimicrobial therapy, broad debridement, exhaustive cleaning, and application of
unprocessed honey dressings. Patients then underwent split-thickness skin grafts or delayed
closure as needed. Topical application of honey reported to be beneficial to the healing process.

Ameh et al (2001) An 11-day old baby who presented with necrotizing fasciitis of the scalp, from which Escherichia
coli was cultured, was treated with parenteral broad-spectrum antibiotics, debridement and the
daily application of a honey dressing. The wound healed with scar tissue over 3 months.

Gurdal et al (2003) 28 patients treated for Fournier's gangrene were evaluated retrospectively. Honey was
used in 6 patients to accelerate wound healing.

Misirlioglu et al (2003) Honey-impregnated gauzes versus hydrocolloid dressings versus saline-soaked gauzes for
skin graft donor sites of 88 patients undergoing skin grafting. Honey-impregnated gauzes
showed faster epithelialisation time and a lower sense of pain than paraffin gauzes and
saline-soaked gauzes. No significant difference between honey-impregnated gauzes and
hydrocolloid dressings with regard to epithelialisation time and sense of pain.

Dunford et al (2000a) A 15-year old male patient with multiple infected skin lesions resulting from meningococcal
septicaemia was treated with honey dressings. An excellent outcome was achieved,
with rapid clearance of the infection and good wound bed preparation facilitating skin grafting.
A reduction in wound malodour was also noted.

Discussion burns than that associated with silver- properties of honey.

The general medical opinion is that a
randomised controlled trial generates
the most reliable data on which a
medical or surgical intervention can be
evaluated. However the importance
of including data from other types of
investigation in a clinical review is also
recognised (Rolfe, 1999). There is
substantial evidence of honey and honey-
based products having been used success-
fully to treat a wide range of acute and
chronic wounds. Honey has been the
subject of a number of randomised,
controlled trials involving patients with
superficial burns, the results of which
have demonstrated that honey gives
more rapid healing of partial-thickness
sulphadiazine (Subrahmanyam, 1991;
Subrahmanyam, 1998) and a polyure-
thane film dressing (OpSite, Smith &
Nephew, UK) (Subrahmanyam, 1993).
Honey has also been shown to be supe-
rior to topical antiseptics (ethanol and
povidone-iodine) in the management
of post-operative wound infections
(Al-Waili and Saloom,1999). The non-
randomised studies, uncontrolled
studies, open studies and case reports
relating to the use of honey in wounds
(Tables 6 -10) provide a plethora of
data that, in conjunction with the data
obtained from the randomised con-
trolled trials (Tables 4-5), can be utilised
to evaluate the reported therapeutic
Antimicrobial activity
It has been reported that the topical
application of honey to wounds can
rapidly clear existing wound infection
(Efem; 1993, Phuapradit and Saropala,
1992), facilitate the healing of deeply
infected surgical wounds (Vardi et al,
1998; Al-Waili and Saloom, 1999;
Cooper et al, 2001; Ahmed et al,
2003), and halt advancing necrotising
fasciitis (Hejase et al,1996). The app-
lication of honey has also been reported
to have healed wounds that have not
responded to treatment with conven-
tional antimicrobial agents (Efem, 1993;
Wood et al, 1997; Vardi et al, 1998;

20
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Dunford et al, 2000a; Cooper et al,
2001) and to have effectively treated
wounds infected with antibiotic-resistant
bacteria (Al-Waili and Saloom,1999),
including methicillin-resistant Staphylo-
coccus aureus (Dunford et al, 2000a;
Cooper et al, 2001; Natarajan et al, 2001).
Anti-inflammatory activity
Efem (1993), Hejase et al (1996),
Subrahmanyam (1996) and
Subrahmanyam (1998) all report a
reduction in symptoms of excessive
inflammation following the application
of honey to wounds. Subrahmanyam
(1993) describes honey having a
soothing effect when applied to burns.
Debriding action
A number of publications describe
the rapid debridement of wounds
with honey, thereby facilitating
good wound bed preparation
(Subrahmanyam, 1991; Efem, 1993;
Subrahmanyam, 1993; Hejase et al,
1996; Subrahmanyam, 1996).
Reduction of wound malodour
Subrahmanyam (1991), Phuapradit
and Saropala (1992), Efem (1993),
Subrahmanyam (1993), Hejase et al
(1996), Subrahmanyam (1996),
Dunford et al (2000a), Alcaraz and
Kelly (2002), Ahmed et al (2003) all
report on the ability of honey to
rapidly deodorise wounds.
Cost-effectiveness
In addition to the clinical advantages of
using honey on wounds, there is an
economical advantage to its use. This
has been demonstrated in terms of cost
savings when honey is compared to
conventional treatments and when con-
sideration is given to the rapid healing
rates that can be achieved with honey.
In the report of a small pilot study
carried out in New Zealand (Wood et
al, 1997), it is stated that eight weeks
of treatment with a honey-based
product cost NZ$8 compared with
an estimate of NZ$40 for the hydro-
colloid, Duoderm (ConvaTec, UK).
In a trial on patients with dehisced
abdominal wounds following Caesarean
section, the use of honey was reported
to have healed wounds twice as fast
as a regime of cleansing with hydrogen
peroxide solution, Dakin’s solution,
and packing with saline-soaked gauze,
thereby significantly reducing the
period of hospitalisation (Al-Waili and
Saloom,1999).
Conclusion
The findings of this literature review
demonstrate that the evidence for the
use of honey-based products in wound
care is substantial. They also strongly
suggest that more evidence on safety
and efficacy exists for honey-based
products than for many of the wound
treatments that health professionals
take for granted.
In honey, healthcare professionals have
access to a naturally-occurring agent
that has been subjected to extensive
scientific and clinical evaluations, the
results of which show it to be a safe and
highly effective treatment for a wide
range of wound types.
In the last decade, the use of honey
in wound management has grown
sub-stantially. Clinical research and
other scientific programmes are
identifying rational explanations for
the way honey works and the benefits
that it can offer to those involved in
providing wound care. Quoting from
an article about honey that was
published in the Journal of the Royal
Society of Medicine, “The time has
now come for conventional medicine
to lift the blinds off this ‘traditional
remedy’ and give it its due
recognition.” (Zumla and Lulat, 1989).
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Clinical REVIEW
Key Points
There has been a substantial
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honey to treat wounds.
The published literature
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Honey has been used
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White R, Cooper R, Molan P, Eds. Honey: Zumla A, Lulat A (1989) Honey – a remedy
A modern wound management product. Wounds rediscovered. Journal of the Royal Society of
UK Publishing, Aberdeen: 33-53 Medicine 82: 384-5
Subrahmanyam M (1991) Topical application
of honey in treatment of burns. British Journal
of Surgery 78 (4): 497-8
Subrahmanyam M (1993) Honey-impregnated
gauze verses polyurethane film (OpSite) in the
treatment of burns - a prospective randomised study.
British Journal of Plastic Surgery 46 (4): 322-3
Subrahmanyam M (1994) Honey-impregnated
gauze versus amniotic membrane in the
treatment of burns. Burns 20 (4): 331-3
Subrahmanyam M (1996) Honey dressing versus
boiled potato peel in the treatment of burns: a
prospective randomized study. Burns 22(6):491-3
Subrahmanyam M (1998) A prospective
randomised clinical and histological study of
superficial burn wound healing with honey
and silver sulphadiazine. Burns 24 (2): 157-61
Subrahmanyam M (1999) Early tangential
excision and skin grafting of moderate burns is
superior to honey dressing: a prospective
randomised trial. Burns 25 (8): 729-31
Suguna L, Chandrakasan G, Thomas Joseph K
(1992) Influence of honey on collagen
metabolism during wound healing in rats. Journal
of Clinical Biochemistry and Nutrition 13: 7-12
Suguna L, Chandrakasan G, Ramamoorthy U,
Thomas Joseph K (1993) Influence of honey
on biochemical and biophysical parameters of
wounds in rats. Journal of Clinical Biochemistry
and Nutrition 14: 91-9
Van der Weyden E (2003) The use of honey for
the treatment of two patients with pressure
ulcers. British Journal of Community Nursing 8
(12 Suppl): S14-S20
Vandeputte J, Van Waeyenberge PH (2003)
Clinical evaluation of L-Mesitran – a honey-
based wound ointment. European Wound
Management Association Journal 3 (2): 8-11
Vardi A, Barzilay Z, Linder N, Cohen HA, Paret
G, Barzilai A (1998) Local application of honey
for treatment of neonatal postoperative wound
infection. Acta Paediatrica 87 (4): 429-32

The Implications for
Honey Dressings in UK
Primary Care
This article outlines an approach to the use of honey within Primary Care and attempts to clarify the potential
role for honey dressings in wound management. The ongoing clinical evaluations of the Mesitran (Medlock
Medical, Oldham, UK) range of honey-based ointments and dressings within the Worcestershire Primary
Care Trusts are reviewed.
Jackie Stephen-Haynes RGN DN DipH BSc (Hons) ANP, MSC, PG Cert R PG Dip Ed.
KEY WORDS
Chronic wounds
Honey dressings
Primary care
Wound Healing Continuum
Wound Management in Primary Care
Recent research into the cellular and
molecular environment of the wound
bed has significantly increased our know-
ledge of chronic wounds (Harris et al,
1995), with a clearer understanding of
the bacterial balance, moisture balance
and the role of proteolytic enzymes
increasingly emerging (Greener et al
2005).
In most instances, the challenge of
wound care within the Primary Care
setting will be to achieve cosmetically
acceptable healing in the shortest pos-
sible time. A thorough holistic
assessment will identify important
information about the condition of the
patient, the skin and the wound, and
can assist the clinician in determining
the objective of treatment. The quality
of life of patients can be significantly
affected by wound malodour, pain,
infection (and the risk of infection),
Jackie Stephen-Haynes RGN DN DipH BSc (Hons) ANP, MSC,
PG Cert R PG Dip Ed. Consultant Lecturer and Practitioner in
Tissue Viability for Worcestershire Primary Care Trusts and
University Worcester.
Clinical REVIEW
exudate and oedema, the management that fulfilled certain biological
of which can, on occasions, take requirements:
priority over the quality and speed of • absorption of excess exudate and
healing. In addition to addressing these toxic substances
challenges, the practitioner seeks to • maintenance of high humidity at the
use interventions that are associated wound dressing interface
with no – or minimal – adverse effects, • uninhibited exchange of gases across
thereby limiting the distress and the dressing
discomfort to patients.Thus, dressings • impermeability to microorganisms
that are non-adherent, non-irritating • insulation of the wound from low
and non-allergenic simplify the task of temperature effects
wound management. Turner (1985) • freedom from particulate and other
emphasised that the optimal micro- contamination
environment for wound healing would • removal without trauma at dressing
be provided by a wound care dressing change
Table 1
Mesitran Products Listed in Drug Tariff
Mesitran Ointment
Preparation containing medical grade honey (47%), lanolin, sunflower oil, cod liver oil,
Calendula officinalis, Aloe barbadensis, vitamins C and E, and zinc oxide
Mesitran Ointment S
Preparation containing medical grade honey (40%), lanolin, vitamins C and E, and
polyethylene glycol. With a lower honey content, Mesitran Ointment S is intended for
use in the debridement and cleansing of sensitive wounds
Mesitran
Sheet hydrogel dressing containing medical grade honey (30%)
Mesitran Border
Sheet hydrogel dressing containing medical grade honey (30%) with adhesive border
Mesitran Mesh
Primary wound contact layer containing medical grade honey (20%)
Wounds UK 23
Clinical REVIEW
Within Primary Care, there is a need
for cost-effective ‘easy to use’ products
to help achieve patient outcomes, and
to assist in the complex work of the
community nurse. Products with more
than one function are of immediate
interest in this respect. The advantages
are clear: a requirement for fewer
dressings leads to reduced wound
management costs. There is also the
benefit of having fewer permutations
of dressings to consider.
Availability of Dressings in
Primary Care
The availability of wound dressings for
use in the community is generally
dictated by the Drug Tariff (Prescription
Pricing Authority, Department of Health,
2005). This publication defines what
may be prescribed in the community and
paid for by the National Health Service.
The renewed interest in the use of
honey on wounds has resulted in the
commercial development of medical
grade honey in a variety of presentations.
A number of honey-based dressings are
currently listed in the Drug Tariff and,
as such, are reimbursable against NHS
prescriptions (FP10 in England and
Wales; GP10 in Scotland). These include
the Mesitran range of ‘CE’ marked
Medical Devices (Table 1).
Honey
Honey possesses a number of thera-
peutic properties which make it an
attractive community option for wound
management. These include: antimicro-
bial activity, anti-inflammatory effects,
and the ability to reduce malodour,
necrotic/sloughy
necrotic
Figure 1. Wound Healing Continuum
24 Wounds UK
promote autolytic debridement, maintain
a moist wound environment, and
stimulate tissue growth (Molan, 2002;
White and Molan, 2005). The activity
of honey against antibiotic-resistant
strains of bacteria (Cooper and Molan,
1999; Dunford et al, 2000; Cooper,
2005) is particularly important to those
working in Primary Care, in view of
the increasing concerns about the
development of community-associated
methicillin-resistant Staphylococcus aureus
(MRSA) (Banning, 2005).
Applied Wound Management in
Primary Care
Applied Wound Management (AWM)
is a decision-making framework that
has been designed to support clinical
decision making and clinical audit in
wound management. It is supported
by three continuums, Wound Healing
(Figure 1), Wound Infection and
Wound Exudate (Gray, 2004).
Following a holistic assessment, and
once wound pathologies have been
established, practitioners can utilise these
continuums to define wound types,
identify key management principles
associated with common wound types,
and formulate appropriate treatment
strategies. The Wound Healing
Continuum provides a useful framework
for the assessment and classification of
wounds, as well as assisting with identi-
fying the aim of wound management.
It is possible to consider the potential
uses of dressings such as honey in rela-
tion to the Advanced Wound Manage-
sloughy/g ranulating g ranulating/epithelialising
sloughy g ranulating
Key Points
• A number of honey-based wound
treatments are listed in the Drug Tariff
• The Mesitran range of honey-based
ointments and dressings appear to
be suitable for use in Primary Care
• Mesitran provides treatment options
for early (Mesitran ointments)
and later-stage healing (Mesitran,
Mesitran Border, Mesitran Mesh)
ment concept. By clearly assessing the
wound, the treatment objectives can
be determined and the mode of applica-
tion of honey can be considered.
According to the Wound Healing
Continuum (Figure 1), wounds are
classified by the predominant tissue
type, and treatment is directed at that
tissue which is farthest to the left in
the continuum. Black, black/yellow
and yellow wounds contain necrotic
tissue and slough, large quantities of
which can delay healing and may
provide a focus for infection (Bradley
et al, 1999). Mesitran Ointment has
been shown to be effective in the
debridement of necrotic and sloughy
material (Vandeputte and Van
Waeyenberge, 2003; Gray et al,
2005). Wounds containing slough
and/or necrotic tissue are often mal-
odorous. The reduction and
elimination of foul smell can also be
accomplished through the use of the
Mesitran ointments (Gray et al 2005).
epithelialisation

The red colour in the Wound Healing
Continuum represents the stage where
good wound bed preparation has been
achieved and healthy granulation tissue
can be observed. Bearing in mind the
importance of controlling excess exudate
and maintaining a moist wound environ-
ment, both of which can be achieved
with honey (White and Molan, 2005),
dressings containing honey such as
Mesitran, Mesitran Border and Mesitran
Mesh are considered appropriate for
the later-stage healing of wounds.
Primary Care-based Case Studies
In the United Kingdom, a large series
of carefully controlled case studies (in
excess of 50 to date) have been under-
taken, in which Mesitran ointments and
dressings have been applied to a typical
range of problem wounds. Preliminary
findings have shown good debridement
and odour management with the
Mesitran products, in addition to good
financial comparisons with other treat-
ments (Gray et al, 2005). Mesitran Mesh
has been evaluated on a cohort of
patients where there is currently limited
evidence to support the clinical decision-
making, including lacerations (e.g. pre-
tibial lacerations and skin tears of the
fragile skin of an elderly patient), and the
initial findings are very promising
(Callaghan R, Evesham, UK personal
communication 2005). Mesitran Mesh
has the advantage of being capable of
gently securing edges of lacerations and
free flaps in position without the need
for adhesives. The Mesitran ointments
can be used in conjunction with the
mesh, should the need arise. In highly
exuding wounds, Mesitran Mesh can
be used as a wound contact layer, with
absorbent dressings such as pads
secured in place on top.
Worcestershire Primary Care Trusts
Formulary and Local Prescribing
There is a significant need for clinical
evidence to guide future practice and the
development of education to support
the use of wound dressings. It is essential
that any wound management formulary
reflects the current evidence for products
available in the specialty of Tissue Viability.
This, however, creates challenges when
many new products are introduced
annually (Morgan, 2004).
The Mesitran products are currently
being evaluated within the Worcester-
shire Primary Care Trusts. These
evaluations are being undertaken to
provide evidence upon which a decision
can be made regarding their listing in the
local formulary, as well as generating
information on which prescribing advice
for nurses can be based.
It is believed that this approach to
dressing evaluation and selection, in
combination with the implementation
of the principles of Applied Wound
Management, will help to optimise the
assessment and treatment of wounds
in the community.
Conclusions
The recent resurgence in interest in
using honey has led to the development
of a number of specific preparations
for use on wounds. A number of these
products, available as ointments and
dressings, are now listed in the Drug
Tariff and can, therefore, be prescribed
by nurses. The Mesitran range of honey-
based wound care products appear to
be suitable for use in the Primary Care
setting, providing treatment options for
early- and late-stage healing. A clinical
evaluation programme currently being
undertaken by the Worcestershire
Primary Care Trusts, and evaluations
being carried out in other parts of the
United Kingdom, will help practitioners
to further their understanding of the
clinical benefits of honey.
References
Banning M (2005) Transmission and
epidemiology of MRSA: current perspectives.
British Journal of Nursing 14 (10): 548-54
Bradley M, Cullum N. Sheldon T (1999) The
debridement of chronic wounds: a systematic
review. Health Technology Assessment 3 (17 Pt 1):
iii-iv, 1-78
Cooper R (2005) The antibacterial activity of
honey. In: White R, Cooper R, Molan P, Eds.
Honey: A modern wound management product.
Wounds UK Publishing, Aberdeen: 24-32
Clinical REVIEW
Cooper R, Molan P (1999) The use of honey as
an antiseptic in managing pseudomonas infection.
Journal of Wound Care 8 (4): 161-4
Dunford, C, Cooper R, Molan P, White R. (2000)
The use of honey in wound management.
Nursing Standard 15 (11): 63-8
Gray D (2004) Applied wound management:
a new conceptual framework in wound
management. Wounds UK Suppl: 3
Gray D, Stephen-Haynes J, Cutting K (2005)
Clinical Case Studies Using Mesitran
Ointment. Poster presentation, Tissue Viability
Society Meeting and 8th European Pressure
Ulcer Advisory Panel Open Meeting Aberdeen,
Scotland, May 2005
Greener B, Hughes A, Bannister N, Douglass J
(2005) Proteases and pH in chronic wounds.
Journal of Wound Care 14 (2): 59-61
Harris I, Yee K, Walters C, Cunliffe W, Kearney
J, Wood E, Ingham, E (1995) Cytokine
and protease levels in healing and non-healing
chronic venous leg ulcers. Experimental
Dermatology 4: 342-9
Molan P (2002) Re-introducing honey in the
management of wounds and ulcers: theory and
practice. Ostomy Wound Management 48 (11):
28-40
Morgan DA (2004) Formulary of wound
management products. Ninth Edition. Euromed
Communications, Haslemere, Surrey: 143
Prescription Pricing Authority, Department of
Health (2005) Drug Tariff October 2005. The
Stationery Office, London
Turner TD (1985) Current and future trends
in wound management 2: modern surgical
dressings. Pharmacy International June: 131-4
Vandeputte J, Van Waeyenberge PH (2003)
Clinical evaluation of L-Mesitran – a honey-
based wound ointment. European Wound
Management Association Journal 3 (2): 8-11
White R, Molan P (2005) A summary of
published clinical research on honey in wound
management. In: White R, Cooper R, Molan P,
Eds. Honey: A modern wound management product.
Wounds UK Publishing, Aberdeen: 130-42
Wounds UK 25
Clinical REVIEW

The Control of Wound

Malodour with Honey-based
Wound Dressings and
Ointments
Malodorous wounds are distressing to patients, their families and carers, and can be challenging for healthcare
professionals to manage. Attention should be given to the physiological and psychological needs of the patient.
A high standard of wound care is required, including specific measures to reduce or eliminate the malodour.
The primary aim of treating malodour is to eliminate or inhibit the growth of the microorganisms responsible.
This can be achieved by cleaning and debridement, and by the use of systemic or topical antimicrobial agents
(e.g. metronidazole). Activated-charcoal dressings can be considered as a secondary measure to absorb and
contain odour. Clinical observations indicate that honey can clear infection from wounds and eliminate malodour
rapidly; this results from its antimicrobial, debriding and specific deodorising properties. Sterile, honey-based
wound care products provide a convenient, well-tolerated and effective means of delivering honey to wounds
and are particularly suited to the management of malodorous wounds.

Rose Cooper PhD, David Gray RGN

nausea and loss of appetite at a time What causes wound malodour?

KEY WORDS
Malodour
Honey
Wound care
The problem of wound malodour
Aversion to malodour is deeply ingrained
in human behaviour. Having a persistent,
foul-smelling wound is extremely dis-
tressing for patients, both psychologically
and physically (Williams and Griffiths,
1999; Hack, 2003; Piggin, 2003; Goode;
2004). It may adversely affect self-esteem
and personal relationships, causing
patients to become apathetic, depressed,
and withdraw from social interaction.
In some cases, the odour may cause
Rose Cooper, PhD, Principal Lecturer in Microbiology, School
of Applied Science, University of Wales Institute Cardiff,
Western Avenue, Cardiff.
David Gray, RGN, Clinical Nurse Specialist, Department of
Tissue Viability, Grampian NHS Trust, Aberdeen.
when good nutrition is particularly
important in promoting effective healing.
Wound malodour is also distressing for
families, friends and carers, who may
reduce contact with the patient because
of their personal embarrassment or
distaste, so increasing the social isolation
of the patient.
Healthcare professionals may also have
difficulty coping with the odour and
the associated problems of the patient.
It is important for them to understand
the profound psychological effect that
other people’s reactions can have on
a patient with a malodorous wound.
Although wound malodour is one of the
most challenging problems for health-
care professionals involved in wound
management, successful eradication of
the odour can have a positive effect
on the patient and the people around
them, as well as providing enormous
personal satisfaction to the person
managing their treatment.
The underlying causes of wound mal-
odour are not fully understood, and
Key Points
• Persistent wound malodour is a
distressing symptom for patients
and their carers
• Both the psychological and physical
needs of the patient should be
considered and, where possible,
addressed
• Measures to eliminate or reduce
wound malodour include cleaning and
debriding the wound, use of topical
or systemic antimicrobial agents, and
the use of odour-absorbing dressings
• Honey possesses debriding,
antimicrobial and rapid deodorising
properties
• Use of honey-based ointments and
dressings is appropriate to consider
for the management of malodorous
wounds

26 Wounds UK

may involve wound infection, colonisa-
tion by anaerobic bacteria, and tissue
degradation or necrosis (Bale et al,
2004). Malodour is not confined to
specific types of wounds. Wounds that
contain a large amount of devitalised
tissue, such as fungating (malignant)
ulcers, chronic leg ulcers and pressure
sores, are particularly prone to malodour
(Haughton and Young, 1995; Williams
and Griffiths, 1999). The presence of
slough and necrotic tissue in these
wounds provides an ideal breeding
ground for microorganisms (Bowler et al,
2001). They frequently become heavily
colonised or infected with bacteria that
produce foul-smelling metabolites.
Anaerobic bacteria usually constitute a
significant proportion of the total
microbial population in wounds. This is
particularly the case in chronic wounds,
and they may influence wound healing
and infection (Bowler, 1998; Bowler
and Davies, 1999). Metabolic products
of anaerobic bacterial decomposition of
devitalised tissue in the wound are
considered to be the main cause of
malodour. Much of the malodour arises
from their production of volatile fatty
acids (i.e. propionic, isobutyric, butyric,
isovaleric, and valeric acid) during lipid
catabolism (Kalinski et al, 2005), but may
also arise from degradation of tissue
proteins, giving rise to sulphur com-
pounds (e.g. mercaptans, sulphides), and
amines (e.g. tyramine, indoles, skatole,
cadaverine and putrescine) (Chen and
Griffiths, 2002). Host-enzyme degra-
dation of devitalised tissue may also be
involved - tissue-degrading enzymes
are prevalent in chronic venous and
pressure ulcers (Rogers et al, 1995;
Herrick et al, 1997; Rogers et al,1999).
The proportion of anaerobic bacteria,
relative to the total number of organisms
present in wounds, is raised in mal-
odorous wounds (Bowler et al, 1999).
From a study of the relationship
between odour severity and the
microorganisms present in leg ulcers,
Bowler et al (1999) identified that
malodour was most frequently
associated with wounds that were
infected with a mixture of anaer-obic
and facultative aerobic bacteria.
Non-malodorous wounds (n=35)
1.4
1.2
Fluid Handling Capability
1.0
0.8
0.6
0.4
0.2
0
Pept
Figure 1. Mean numbers of obligate anaerobic bacterial species/groups per malodorous and non-malodorous infected leg ulcer
(Bowler et al, 1999). Reproduced with permission from Emap Healthcare.
Peptostreptococcus spp
Clostridium spp
Lactobacillus spp
Propionibacterium spp
Eubacterium spp
Bacteroides spp
Pigmenting GNB
Non-pigmenting GNB
Veillonella spp
Fusobacterium spp
The generation of odour was associated
with the presence of specific anaerobic
bacteria, e.g. Bacteroides spp, Prevotella
spp, and Porphyromonas spp, which were
found predominantly in mal-odorous
wounds. Peptostreptococcus spp was
the most frequently isolated bacterial
group in both malodorous and non-
malodorous wounds, and consequently
its significance in malodour generation
is less clear (Figure 1). Organisms that
were more evident in non-malodorous
infected ulcers – and therefore less
likely to be associated with chronic
wound malodour – included coagulase
negative staphylococci, Staphylococcus
aureus, non-faecal streptococci,
Corynebacterium spp, yeasts,
Clostridium spp, Lactobacillus spp,
Propionibacterium spp, Eubacterium
spp, Veillonella spp and Fusobacterium
spp. Facultatively anaerobic bacteria
can themselves produce odour,
although their main and significant
role may be in facilitating the
malodour produced by strictly
Clinical REVIEW
Malodorous wounds (n=8)
Clos Lact Prop Euba Bact B. ur Pigm Non-p Veil Fuso
P. asaccharolyticus, P. indolicus, P. prevotii, P. anaerobius, P. magnus,
P. tetradius, P. micros, S. intermedius
C. sporogenes, C. clostridioforme, C. perfringens
L. acidophilus
P. acnes, P. avidum
E. aerofaciens
B. fragilis, B distasonis
Prevotella loescheii, Pr. corporis, Porphyromonas asaccharolytica, P. gingivalis
Prevotella oralis, Pr. bivia, Pr. buccalis, Prevotella sp.
V.dispar
F. necrophorum
anaerobic bacteria (Bowler et al,
1999).
The relationship between numbers
of microorganisms and infection or
malodour in heavily colonised mixed-
population wounds is complex and
not well defined. Although infected
chronic wounds are generally
malodorous, this is not always the
case. Conversely, not all malodorous
wounds are infected (Bowler et al,
1999). Nevertheless, reducing
microbial load is a priority aim for
managing wound malodour.
The management of malodour in wounds
The presence of malodour in a wound
is an alerting signal of a condition that
requires immediate attention. For
example, it may be an indication of an
impending infection, and prompt action
may be able to reduce the risk. In some
cases, it may be due to an incurable
condition (e.g. a malignant tumour), in
which case, effective management of
Wounds UK 27
Clinical REVIEW
the odour is required to promote quality
of life and the patient’s sense of well-
being (Groscott, 2000; Naylor, 2001;
Adderley, 2004; Holloway, 2004). The
principles that guide the reduction of
malodour are essentially the same for
all malodorous wounds. Unfortunately,
there is little evidence from well-
controlled randomised clinical studies
to guide practice, and protocols for the
management of such wounds are not
available (Groscott, 2000). Much of
the knowledge and experience comes
from the management of malodour in
fungating wounds, which are often
extremely difficult to manage. However,
even in this area, there appears to be
little clinical research carried out
(Draper, 2005).
The management of a malodorous
wound requires a patient-centred,
holistic approach to treatment (Collier,
2000). Both physical and psychological
needs should be addressed (Hack,
2003). As well as carrying out a detailed
medical assessment to identify the cause
of the malodour and the appropriate
wound care needs, efforts should be
made to understand the patients’ views,
alleviate any guilt and concerns they
have about their condition, and
achieve concordance in the treatment
approach adopted.
Not everybody is similarly sensitive to
smells, and it is possible for individuals
to become desensitised to odour. This
can apply to healthcare professionals,
as well as to patients. It is important,
therefore, that subjective reporting of
odour by patients and carers is used to
guide treatment (PRODIGY 2005).
A descriptive assessment of odour
can provide important information
because the type and amount of odour
may indicate a change in wound status.
A qualitative tool, such as that
proposed by Haughton and Young
(1995) (Table1), can be useful for
assessing progress. It enables the
healthcare team to share a common
perception of the extent of the
problem and any changes that occur,
and provides reassurance to the
patient of improvement.
28 Wounds UK
The adoption of best practice approach- Use of antibiotics:
es to heal a wound (e.g. treating If the wound is infected, appropriate
infection, debriding, managing exudate) systemic antibiotic or antimicrobial
will assist in control of wound odour, treatment is required. It is important
regardless of any specific odour-reducing to be aware of sensitivity, resistance
measures. However, specific steps to and toxicity issues (Collier, 2000).
manage the odour may also be required. Metronidazole has good anaerobic
These should aim primarily to eliminate antibacterial activity, and can be
the cause of the malodour, which in most extremely effective in reducing odour
cases means eradicating or restricting when given orally or when applied
the growth of the organisms responsible topically as a gel to wounds (Moody,
for the odour. 1998; Williams and Griffiths, 1999;
Clark, 2002; Bale et al, 2004; Kalinski
Cleansing and debriding the wound: et al, 2005). Oral therapy may not be
Cleansing the wound, and debriding it appropriate if there is a compromised
of necrotic tissue, are important first blood supply to the affected tissue,
steps in the treatment of malodorous and is often associated with adverse
wounds. Debridement exposes healthy events, such as nausea and vomiting.
perfused tissue, which is required to The restriction on alcohol with oral
initiate healing, reduces the risk of in- metronidazole may further impair
fection, and effectively reduces microbial a patient’s quality of life (Kalinski et al,
contamination and associated malodour 2005). Oral metronidazole is usually
(Bowler et al, 2001). Debridement can given at a dose of 400mg three-times
be carried out by a number of different daily, whereas metronidazole gel (0.75%
means. Surgical debridement can be or 0.8%) can be applied liberally once
considered, but is often not appropriate or twice a day. Topical metronidazole
for fungating wounds because of their is more expensive than oral treatment,
tendency to bleed. Other approaches but is associated with fewer side effects.
include autolytic debridement (e.g. However, the use of antibiotics always
hydrogels, hydrocolloids, honey) which provides opportunities to select resistant
provide a moist wound environment, strains, and inappropriate use must be
enzymes (e.g. strepokinase/ avoided. Although metronidazole gel is
streptodornase), and the use of maggots licensed in the UK for controlling odour
(Williams and Griffiths, 1999). Honey is associated with fungating tumours,
also reported to contribute to debride- venous ulcers, and pressure sores, it is
ment (Molan, 2001). generally reserved for use in fungating
Table 1
Odour Assessment Scoring Tool (Haughton and Young, 1995)
Score Assessment
Strong Odour is evident on entering room, with dressing intact
( 2 _ 3m from patient )
Moderate Odour is evident on entering the room, with the dressing
removed ( 2 _ 3m from patient )
Slight Odour is evident at close proximity to the patient, with the
dressing removed
No Odour No odour is evident, even at the patient’s bedside and with
the dressing removed

tumours. Several other topical agents
that have antibacterial activity, and may
have an effect in reducing odour, include
the use of maggots, sugar paste,
cadexomer-iodine, silver-containing
dressings (e.g. hydrofibres, hydrogels,
foams) and silver sulfadiazine cream
(Hampton, 2004). The incorporation
of honey into wound care products
provides another effective alternative
to control odour. (See below.)
Odour-absorbing dressings:
Odour-absorbing dressings can also be
considered as a secondary measure.
Activated-charcoal dressings can be very
effective (Williams, 1999; Chen and
Griffiths, 2000; Williams, 2001). Many
are available, either as primary or
secondary dressings; however, there
may be marked differences in their
odour-absorbing properties (Thomas et
al, 1998). Their effectiveness can reduce
markedly if they become wet with
exudate, and they may need to be
replaced regularly to maintain effective
control of odour (PRODIGY team,
2005). Stale exudate can itself have an
offensive odour, and effective exudate
management and dressing changes are
required to prevent saturated dressings
themselves becoming malodorous
(Adderley, 2004). The use of adequate
ventilation and frequent changing of
clothing and bed linen, as well as the
use of deodorants or air fresheners, can
help, but seldom adequately controls
the odour (Kalinski et al, 2005), and
should not replace other control
measures. It should also be borne in
mind that perfumes and deodorants
only mask the smell and may leave the
patient/carer with an unpleasant
association with certain fragrances
(Haughton and Young, 1995).
The potential of honey in
reducing malodour
Increasing clinical evidence supports the
view that honey is a safe and effective
bioactive wound dressing that provides
rapid wound healing (White and Molan,
2005), and is suitable for use in a wide
range of wounds. Honey appears to
have the properties of ‘kick-starting’ the
healing process in chronic wounds,
where other treatments have proved
Table 2
Possible modes of deodorising activity of honey in wounds
Antimicrobial action
• Production of hydrogen peroxide
• Action of non-peroxide components
• Acidity
• Osmotic activity
• Stimulation of immune system
Debriding (autolytic)
• Moist wound environment
• Activation of proteases by hydrogen peroxide
Deodorising
• Preferential glucose metabolism by the infecting bacteria to lactic acid, instead of
metabolism of amino acids to malodorous ammonia, amines and sulphur compounds
ineffective (White and Molan, 2005).
Honey is particularly suitable for use in
the management of malodorous wounds
because of its wide range of beneficial
properties (Molan, 2005), which include
antibacterial, debriding, and specific
deodorising activity (Table 2). Clinical
reports of the value of honey-based
wound care products in reducing
malodour in wounds are increasing
(Kingsley, 2001; Vandeputte and Van
Waeyenberge, 2003; Dunford and
Hanano, 2004; Dunford, 2005; Owen,
2005). Honey has been reported to
clear existing wound infections, both
from wounds that have failed to respond
to ‘normal management’ and those
colonised or infected with methicillin-
resistant Staphylococcus aureus (MRSA)
(Dunford et al, 2000; Natarajan et al
2001; Namias, 2003; Molan and Betts,
2004).
Honey has inhibitory activity against a
broad range of microbial species that are
found in wounds and are responsible
for infection and wound odour
(Molan, 1999; Willix et al, 1992; Molan,
2001; Cooper et al, 2002; Lusby et al,
2002). It had also been reported to
inhibit anaerobic bacteria (Elbagoury
and Rasmy, 1993). Unlike sugar paste,
its antimicrobial activity is not solely
dependent on its osmotic effect (low
water activity), and is retained on
Clinical REVIEW
dilution (Willix et al, 1992; Cooper et
al 2002; Elbagoury & Rasmy, 1993).
Honey’s bactericidal activity is a result
of several mechanisms of action in
addition to its osmotic effect. These
include its acidity - pH is typically 3.5
(Molan, 1999) - the presence of
specific antibacterial components of
plant origin (bioflavonoids), and, most
importantly, its ability to generate
hydrogen peroxide in the wound.
Hydrogen peroxide arises from the
activity of oxidase enzymes in the
honey, which become active on
dilution with wound fluids (Molan et al,
2001). It is produced continuously at
an effective antimicrobial, non-toxic,
concentration after application, for at
least 24 hours (Molan, 1999).
The specific deodorising properties of
honey, as distinct from its antibacterial
and debriding activity, are thought to
result from its high glucose content.
Oxidation of glucose by bacteria yields
odourless metabolites such as carbon
dioxide and water, yet anaerobic
metabolism by fermentative pathways
gives rise to complex mixtures of
organic metabolites that depend on
the species present. Many of these
products are malodorous.
Wounds UK 29
Clinical REVIEW
As well as direct antimicrobial action,
the ability of honey to activate the
immune system in the wound may also
play a role in clearing infection from
wounds (Molan, 2001). The application
of honey to wounds has been suggested
to result in: multiplication of B-lympho-
cytes and T-lymphocytes; activation of
neutrophils; release of cytokines by
monocytes; supply of glucose for
‘respiratory burst’ and for energy for
production in macrophages; and assist
in bacteria-destroying activity of macro-
phages through its acidity (Molan, 1999).
Honey also has debriding activity. This
may be a result of the moist wound
healing environment created and/or
activation of protease enzymes in the
wound tissues by the generated
hydrogen peroxide. The high osmolarity
of the honey means that these enzymes
are continually replenished in the wound
bed, by the drawing of lymph fluid into
the wound (White and Molan, 2005).
Summary
Malodour can be a distressing symptom
of many types of wounds and, if severe
and persistent, can pervade normal
life. Healthcare professionals need to
consider both the physical and psycho-
logical needs of the patient when assess-
ing and treating malodorous wounds.
As well as treating any infection and
applying normal high standards of wound
care, specific measures can be taken to
eliminate or reduce the impact of wound
malodour. Secondary approaches to
absorb or mask the odour can be used:
for example, activated charcoal dressings.
However, the primary aim of treating
malodour should be to identify and
remove the source of the odour, which
means eliminating the putrefying necrotic
tissue or slough, and the microorganisms
responsible for the malodour (generally
anaerobic bacteria) from the wound.
Thorough cleaning and debridement of
the wound may be sufficient to remove
the odour. However, systemic or topical
antimicrobial agents (e.g. metronidazole)
may be required. Honey is appropriate
to consider as it has antibacterial,
debriding and specific deodorising prop-
erties. Sterile, honey-based wound care
products seem to provide a convenient,
well-tolerated and effective means of
30 Wounds UK
delivering honey to wounds and are
particularly appropriate for use in the
treatment of malodorous wounds.
References
Adderley U (2004) Managing wound
malodour: from antibiotics to honey. Nurs
Pract(5): 69–70
Bale S, Tebble T, Price P (2004) A topical
metronidazole gel used to treat malodorous
wounds. Br J Nurs 13(11) Suppl: S4–S11
Bowler PG (1998) The anaerobic and aerobic
microbiology of wounds: a review. Wounds
10(6): 70– 8
Bowler PG, Davies BJ (1999) The microbiology of
acute and chronic wounds. Wounds 11(4): 72– 8
Bowler PG, Davies BJ, Jones SA (1999)
Microbial involvement in chronic wound
malodour. J Wound Care 8(5): 216– 8
Bowler PG, Duerden BI, Armstrong DG (2001)
Wound microbiology and associated
approaches to wound management. Clin
Microbiol Rev 14(2): 244 – 69
Chen JC, Griffiths B (2002) CarboFlex odour
control dressing. ConvaTec Ltd. Deeside CH5
2NU. UK.
Clark J (2002). Metronidazole gel in managing
malodorous fungating wounds. Br J Nurs 11(6)
Suppl: S54– S60
Collier M (2000) Malodorous and infected
wounds: a patient-centred approach.
Nurs Resid Care 2(9): 422–4
Cooper RA, Molan PC, Harding DG (2002)
The sensitivity to honey of gram-positive cocci
of clinical significance isolated from wounds.
J Appl Microbiol 93: 57– 63
Draper C (2005). The management of
malodour and exudate in fungating wounds.
Br J Nurs 14(11) Suppl: S4 – 11
Dunford CE (2005) .The use of honey in
Wound Management. In: White R, Cooper R,
Molan P, Eds. Honey: A modern wound
management product. Wounds UK Publishing,
Aberdeen: 130 –42.
Dunford CE, Hanano R (2004) Acceptability of
patients to a honey dressing for non-healing
venous leg ulcers. J Wound Care 13(5): 193–7
Dunford C, Cooper RA, Molan PC, White RJ
(2000) The use of Honey in Wound
Management. Nursing Standard 15 (11): 63– 8
Goode ML (2004) Psychological needs of
patients when dressing a fungating wound: a
literature review. J Wound Care 13(9):380-2.
Groscott C (2000) The management of fungating
wounds malignant wounds J Wound Care 9: 4–9
Hack A (2003) Malodourous wounds – taking
the patient’s perspective into account. J Wound
Care 12(8):319-21.
Hampton S (2004) Managing symptoms of
fungating wounds. J Commun Nurs 18(10): 22–8
Haughton W, Young T (1995). Common
problems in wound care: malodorous wounds.
Br J Nurs 4(16): 959– 63
Herrick S, Ashcroft G, Ireland G, Horan M,
McCollum C, Ferguson M (1997) Up-regulation
of elastase in acute wounds of healthy aged
humans and chronic venous leg-ulcers are
associated with matrix degradation. Lab Invest
77: 281– 8
Holloway S (2004) Recognising and treating
the cause of malodorous wounds. Prof Nurse
19(7): 380 – 4.
Kalinski C, Shnepf M, Laboy D, et al (2005)
Effectiveness of a topical formulation containing
metronidazole for wound odour and exudate
control. Wounds 17(4): 84–90
Kingsley A (2001) The use of honey in the
treatment of infected wounds: case studies. Br
J Nurs 10(22)suppl: S13-20
Lusby PE, Coombes A, Wilkinson JM (2002)
Honey: a potent agent for wound healing?
J Wound Ostomy Cont Nurs 29(6): 295–300
Molan PC (1999) The role of honey in the man-
agement of wounds. J Wound Care 8(8):415-8.
 Clinical REVIEW

Molan PC (2001) Honey as a topical agent for
treatment of infected wounds. World Wide
Wounds. Available at:
http://www.worldwidewounds.com/
Accessed: 10th October 2005
Molan PC, Betts JA (2004) Clinical usage of
honey as a wound dressing: an update. J
Wound Care 13(9): 353–7
Molan P (2005) Mode of Action. Honey:
A modern wound management product. Wounds
UK Publishing, Aberdeen: 1–23
Moody M (1998). Metrotop: a topical
antimicrobial agent for malodorous wounds.
Int J Palliat Nurs 4(3): 148–51
Namias N (2003) Honey in the management of
infections. Surg Infect 4(2): 219–26
Natarajan S, Williamson D, Grey J, Harding KG,
Cooper RA (2001) Healing of an MRSA-
colonized, hydroxurea induced leg ulcer with
honey. J Derm Treat 12(1): 33–6
Naylor W (2001) Assessment and management
of pain in fungating wounds. Br J Nurs 10(22
Suppl):S33-6, S38, S40, passim.
Vandeputte J, Van Waeyenberge PH (2003)
Clinical evaluation of L-Mesitran – a honey-
based wound ointment. Eur Wound Manag
Assoc J 3(2): 8–11
White R, Molan P (2005) A summary of
published clinical research on honey in wound
management. In: White R, Cooper R, Molan P,
eds. Honey: A modern wound management
product. Wounds UK Publishing, Aberdeen:
130–42
Williams C (1999). CliniSorb activated
charcoal dressing for odour control. Br J Nurs
15(8): 1016–9
Williams C (2001) Role of CarboFlex in the
nursing management of wound odour. Br J
Nurs 10(2): 122–4
William K, Griffiths E (1999) Malodorous
wounds: causes and treatments. Nurs Resid
Care 1(5): 276–85
Willix DJ, Molan PC, Harfoot CG (1992) A
comparison of the sensitivity of wound-infecting
species of bacteria to the antibacterial activity
of manuka honey and other honey J Appl Bact
73: 388–94

Piggin P (2003) Malodorous fungating wounds:

uncertain concepts underlying the management
of social isolation. Intl J Palliat Nurs 9(5): 216–21

PRODIGY team (2005) PRODIGY Guidance -

Palliative care – malodorous malignant ulcers
of skin. Available at: http://www.prodigy.nhs.uk/
Accessed: 10th October 2005

Rogers AA, Burnett S, Moore JC et al (1995).

Involvement of proteolytic enzymes —
plasminogen activators and matrix
metalloproteinases – in the pathophysiology of
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Rogers AA, Burnett S, Lindholm C et al (1999)

Expression of tissue-type and urokinase type
plasminogen activators in chronic venous
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Odour absorbing dressings a comparative study.
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Wounds UK 31
Case STUDY

Mesitran Ointment Case

Studies
This paper will present five case studies in which Mesitran Honey ointments have been used in the
management of pressure ulcers. The ointments used offer a variety of features associated with honey
treatments: a debriding action, a reduction in malodour, a reduction in bacterial loading and the
promotion of granulation. In each of the cases presented in this paper, the subjects had long-standing
medical conditions which could result in delayed wound healing and thus represent a significant
challenge to the treatment employed.

David Gray RGN, Richard White PhD.

Introduction in a primary care setting in 2003. In Elderly Units across the UK .

Honey as a wound management dres-
sing has a long history and has under-
gone a transition into a modern wound
management dressing in recent years,
as described by Ahmed et al (2003).
White and Molan (2005) described the
published research relating to honey
in wound management and found a wide
range of trials suggestive of the positive
effects of the treatment. However, it is
important to remember that the wounds
we are faced with today are not the
wounds we were faced with two or
three decades ago. With an ever-
increasing elderly population, those in-
volved in the care of the older patient
are today faced with individuals who
have complex medical problems such
as diabetes and cardiac failure, which
complicate wound management, and
require a co-ordinated approach from
both nursing and medical staff to
maximise the chances of healing.
Vandeputte and Van Waeyenberge
(2003) studied the effects of Mesitran
Ointment across a wide variety of
different types of wound and patients
David Gray , Clinical Nurse Specialist: and Richard White,
Senior Research Fellow, Department of Tissue Viability,
Aberdeen Royal Infirmary, Grampian Health Services,
Aberdeen.
this study, 89 subjects were recruited
and data collected via a web-based
data collection system. While this was
a time-consuming study, the poor
reporting of the methodology does
undermine many of the results
obtained. However, one interesting
fact did emerge from this study: using
the same web-based methodology, it
was possible to compare two similar
groups of subjects recruited from the
same centres over a similar period of
time. One group was treated using
Mesitran Ointment and the other
with modern wound manage-ment
products selected at the discretion of
the staff involved in the patients’ care.
In all types of wounds – skin tears,
burns, venous leg ulcers and pressure
ulcers – the healing rates were
observed to be faster in the Mesitran
group than in the standard group.
While the deficiencies in this study
cannot be overlooked, the results of
this comparison with standard
treatment did suggest that Mesitran
Ointment may offer some benefit in
the management of pressure ulcers.
The authors present a sample of patients
with pressure ulcers who have been
managed using Mesitran Ointment as
part of their treatment regime. All of
these patients presented with complex
medical histories, representative of
patients cared for in Medicine for the
Location
All of the cases reported in this article
were recruited as a part of a multi-
centre clinical audit investigating the
clinical performance of the honey-
based ointment, Mesitran. The subjects
were recruited from referrals made
to the Department of Tissue Viability
from a 300-bed hospital over a six-
month period.
Products Used/ General Management
All of the subjects presented in this
paper were treated using the Ointment
version of the Mesitran range as a
primary dressing, with adhesive or non-
adhesive foam dressings (Lyofoam,
Medlock Medical, UK) as secondary
dressing. The limbs of those with heel
pressure ulcers were wrapped in toe-
to-knee Soffban (Smith & Nephew,
UK) bandages and Tubifast Blue Line
(Medlock Medical, UK). White and
Yellow Soft Paraffin ointment was used
on the non-damaged skin from toe to
knee, limb elevation encouraged where
possible, and heel protectors such as
the Repose Heel Boot (Frontier Medical,
UK) utilised as required. All of the
patients studied were cared for in line
with the Best Practice Statement for
Pressure Ulcer Prevention (2002), and
pressure-reducing mattresses and
cushion were provided as required.

32 Wounds UK

Methodology
Each subject provided informed consent
before recruitment to the study. Data
was collected on a weekly basis for the
duration of their participation. Images
were taken using a digital camera at
each review.
CASES
Case 1
Overview: A 97-year-old man was
referred as a result of a small pressure
ulcer to the heel, which had failed to
respond to treatment with a hydrocolloid
over four weeks. He had a complicated
medical history with advanced cardiac
failure, prostate cancer, and long-standing
peripheral vascular disease presenting
barriers to healing.
Wound at first review
Pressure ulcer to the heel:
2cm x 2cm.
100% of the wound bed covered with
slough.
No evidence of wound infection.
Treatment
Daily Mesitran Ointment with Lyofoam
as a secondary dressing, secured with
a toe-to-knee Softban bandage and
Tubifast Blue Line.
Summary
After three weeks of the treatment, this
patient was transferred to another
facility and discharged from the study.
Debridement was achieved, with the
promotion of granulation and a decrease
in the size of the wound observed.
Wound at final review – three weeks
Pressure Ulcer to the Heel:
0.5cm x 1cm.
100% of the wound bed covered with
granulation.
No evidence of wound infection.
Case 2
Overview: In this case, a 70-year-old
man suffering from advanced lung cancer
was referred with a malodorous wound
which presented a significant reduction
in quality of life for the subject. Discharge
was planned for two weeks following
the initial referral.
Wound at first review
Pressure ulcer to the sacrum:
8cm x 4.5cm.
90% of the wound bed covered with
slough, 10% granulating.
Malodorous wound with a high risk of
developing infection.
Treatment
Daily Mesitran Ointment with Lyofoam
Adhesive as a secondary dressing.
Case STUDY
Summary
After one week of the treatment, this
man was discharged home and dis-
charged from the study with the wound
malodour having been eradicated.
Wound at final review – one week
Pressure ulcer to the sacrum:
8cm x 4.5cm.
80% of the wound bed covered with
slough, 20% granulating.
Malodorous wound with a high risk of
developing infection.
Case 3
Overview: An 80-year-old man was
referred for review of a deteriorating
pressure ulcer on his heel. The wound
had been observed to deteriorate over
a four-week period and was covered
with a hard eschar. The subject had
long- standing Type II diabetes which,
at the time of review, was poorly
controlled as a result of his overall
condition. This man also suffered from
cardiac failure and rheumatoid arthritis.
Wound at first review
Wounds UK 33
Case STUDY
Pressure ulcer to the heel:
9cm x 7cm.
100% of the wound bed covered with
eschar.
No infection present.
Treatment
Daily Mesitran Ointment with Lyofoam
as a secondary dressing, secured with
a toe-to-knee Softban bandage and
Tubifast Blue Line.
Summary
This patient’s overall condition resulted
in a high risk of infection and wound
deterioration. It was observed that,
after one week’s treatment, the
wound was ready for conservative
sharp debridement. After four weeks,
the wound was being desloughed and
the eschar had not reformed.
Wound at final review – four weeks
Pressure ulcer to the heel,
9cm x 7cm.
100% of the wound bed covered with
slough.
No infection present.
Case 4
Overview: A 64-year-old woman who
had previously suffered a cerebral
vascular accident and, as a result, was
severely handicapped and cared for
in a long-term care facility. A pressure
ulcer to the sacrum had proved difficult
to heal and only remained free of
infection while being treated with
cadexomer iodine. During periods when
the cadexomer iodine was
34 Wounds UK
discontinued, in line with the
manufacturer’s guidelines, the wound
excoriated and became infected.
Wound at first review
Pressure ulcer to the sacrum:
1.5cm x 1.5cm x 2.0cm deep,
undermined by 2cm.
Superficial slough on the wound bed,
covered with unhealthy granulation.
Thought to be critically colonised.
Treatment
Daily Mesitran Ointment with Lyofoam
as a secondary dressing, Betnovate
Ointment (GlaxoSmithKline, UK)
to peri-wound area, in response to
adhesive allergy.
Summary
This woman’s wound had regularly
become infected whenever the treat-
ment of cadexomer iodine was
discontinued. During the four weeks
of treatment, the wound did not
become infected and showed signs of
slow healing.
Wound at final review – four weeks
Pressure ulcer to the sacrum:
1.0cm x 1.0cm x 1.0cm deep,
undermined by 1cm.
Superficial slough on the wound bed,
covered with unhealthy granulation.
No evidence of infection.
Case 5
Overview: A lady was referred with a
pressure ulcer to the heel which was
covered with hard eschar. The lady had
suffered a severe cerebral vascular
accident some years previously, and was
left with severe disability, immobility
and unable to swallow. The affected limb
was contracted at a 100 degree angle.
After 1 week of treatment, the eschar
was removed using conservative sharp
debridement and the treatment con-
tinued for a further six weeks, and dis-
continued when the wound was covered
with 100% granulation.
Wound at first review
Pressure ulcer to the heel:
5cm x 5cm.
100% of the wound bed covered with
eschar.
No infection present.
Treatment
Daily Mesitran Ointment with Lyofoam
as a secondary dressing, secured with
a toe-to-knee Softban bandage and
Tubifast Blue Line.
ACKNOWLEDGEMENT
The authors wish to recognise the contribution
made to this paper by the patients recruited,
their relatives and the staff involved in their care
at Woodend Hospital, Aberdeen.
 Case STUDY

medical problems, there is a high chance

Wound at three-week review
Pressure ulcer to the heel:
5cm x 5cm.
90% of the wound bed covered with
granulation, with 10% slough.
No infection present.
Treatment
Daily Mesitran Ointment with Lyofoam
as a secondary dressing, secured with
a toe-to-knee Softban bandage and
Tubifast Blue Line.
Summary
This lady’s overall condition could have
presented a significant barrier to healing
but, after three weeks, the combination
of the ointment and conservative sharp
debridement resulted in the removal
of most of the eschar and slough. The
subsequent four weeks of treatment
resulted in the promotion of granulation
and a reduction in the surface area of
the wound.
Wound at final review – seven weeks
Pressure ulcer to the heel:
4.0cm x 4.0cm.
100% of the wound bed covered with
granulation.
No infection present.
Conclusion
In each of the cases presented in this
paper, the subjects recruited faced sig-
nificant challenges in achieving progress
with wound healing, as a result of their
overall condition. As the elderly popu-
lation grows and the number of patients
with complex medical conditions and
wounds such as pressure ulcers
increases, it is vital that we explore new
methods of wound management.
Methods of speeding healing, such as
debridement and the promotion of gran-
ulation where possible and the effective
management of symptoms such as mal-
odour, require our consideration. For
many elderly patients with complex
that their wound may not fully heal,
but may be present for many months or
years before they succumb to their
chronic disease. It should be recognised
that these case reports are small in num-
ber and further research is required in
this patient group to establish the full
impact of this treatment. However, in
the cases presented in this paper, it is
clear that the ointment played a signif-
icant part in the effective management
of the wounds and the symptoms
associated with them.
Declaration of Interest
This study was funded by Medlock
Medical.
References
Ahmed AKJ, Hoekstra MJ, Hage JJ, Karim RB
(2003) Honey-medicated dressing: transformation
of an ancient remedy into modern therapy. Ann
Plast Surg 50 (2): 143–8
Best Practice Statement for the prevention of
pressure ulcers (2003) NHS Quality Improve-
ment Scotland Edinburgh.
Molan P (2005) Mode of action. In: White R J,
Cooper R, Molan P, eds. Honey: A modern wound
management product. Wounds UK Publishing,
Aberdeen: 1–23
Vandeputte J, Van Waeyenberge PH (2003)
Clinical evaluation of L-Mesitran – a honey-
based wound ointment. Eur Wound Manage
Assoc J 3(2): 8–11
White R J, Molan P (2005) A summary of
published clinical research on honey in wound
management. In: White R J, Cooper R, Molan P,
eds. Honey: A modern wound management product.
Wounds UK Publishing, Aberdeen: 130–42

Table 1
Overview of cases
SUBJECT’S SUBJECT’S MEDICAL CONDITIONS WOUND WOUND WOUND STATE WOUND SIZE OUTCOME OINTMENT
AGE SEX TYPE LOCATION ON 1st REVIEW ON 1st REVIEW MECHANISM

97 Male Peripheral Vascular Disease Pressure Ulcer Heel 100% Slough 2cm x 2cm 100% Debridement
Cardiac Failure granulation and promotion
Prostate Cancer of granulation
70 Male Advanced Lung Cancer Pressure Ulcer Sacrum 100% Slough 8cm x 4.5cm Malodour Removal of
removed malodour
80 Male Type II Diabetic Pressure Ulcer Heel 100% Eschar 9cm x 7cm Eschar Facilitating
Cardiac Failure debrided conservative sharp
Rheumatoid Arthritis debridement
64 Female Cerebral Vascular Accident Pressure Ulcer Sacrum Delayed healing 1.5cm x1.5cm Bioburden Bioburden reduction
with heavy reduced. promoted healing
wound bioburden observed Healing observed
87 Female Cerebral Vascular Accident Pressure Ulcer Heel 100% eschar 5cm x 5cm Debridment Debridement
leading to 100% and promotion
granulation of granulation

Wounds UK 35
Case STUDY

Preliminary Findings of
Case Study Evaluations of
Honey Dressings
A series of case studies have been undertaken at a number of clinical centres, evaluating a range of new, honey-based
wound dressings. The primary aim of these investigations was to evaluate the cleansing, debriding and malodour
reducing properties of Mesitran Ointment and Mesitran Ointment S (Medlock Medical, Oldham, UK). This is in line with
the current focus on wound bed preparation (Beitz, 2005; Davies et al, 2005). Secondary end-points of patient
perceptions, healing and user acceptability were also evaluated.

David Gray RGN, Keith Cutting RN MN MSc,

Jackie Stephen-Haynes RGN DN DipH BSc (Hons) AMP MSc PG Cert R PG Dip Ed.

1998; Molan, 2002). Other properties debride a variety of wounds, ranging

KEY WORDS
Leg ulcers
Eschar
Malodour control
Honey-based wound dressings
Introduction
Preparing a clean wound bed has been
shown to be a prerequisite to advance
the healing of chronic and acute wounds
(Davies et al, 2005). The preparation
of wounds to reach this ‘clean wound
bed’ status inevitably involves some
form of debridement using, for example,
surgical, chemical, enzymatic or dressing-
associated techniques (such as the use
of a hydrogel under occlusive dressings).
The debriding effect of honey is well
recognised in the literature (Efem,
David Gray RGN, Clinical Nurse Specialist, Department of
Tissue Viability, Aberdeen Royal Infirmary, Grampian Health
Services, Aberdeen. Keith Cutting RN MN MSc, Vascular Nurse
Specialist, Ealing Hospital NHS Trust, London and Principal
Lecturer in Health Studies BCUC. Jackie Stephen-Haynes RGN
DN DipH BSc (Hons) AMP MSc PG Cert R PG Dip Ed, Consultant
Lecturer and Practitioner in Tissue Viability for Worcestershire
Primary Care Trusts and University College Worcester.
of honey that have been shown to be from black heel pressure ulcers with
beneficial to wound healing include: its hard necrotic tissue to venous ulcers
anti-inflammatory properties (Efem,1993; consisting of sloughy, wet tissue. Nurses
Subrahmanyam,1998), its antibacterial were provided with a detailed ques-
properties (White and Molan, 2005); and tionnaire to record their observations
its ability to promote healing (Dunford, on the physical handling of the ointments
2005). Recently, a number of new and the patients’ perception of pain
dressings containing honey have become throughout the treatment regime.
available to practitioners. Mesitran is a
range of honey-based dressings and Methods
ointments that can be used to treat a A preliminary evaluation involving
wide range of wound types. 25 patients with a variety of wounds
(e.g. venous and arterial leg ulcers,
In a series of documented case pressure ulcers, pyoderma gangreno-
studies, two novel honey-based sum, burns and acute trauma wounds)
ointments – Mesitran Ointment and has been undertaken within two
Mesitran Ointment S – were used to hospitals and one primary care setting.
Key Points
• Interim results of a series of case studies show that Mesitran
ointments are good debriding agents and can be used to manage
wound malodour
• Mesitran ointments were associated with good user and patient
acceptability
• The wounds treated with the Mesitran products to date have
demonstrated good progress

36 Wounds UK
 Case STUDY

Patients were screened before enrol-
ment to establish their suitability for
inclusion in the study. The criteria for
inclusion were: wounds with slough or
necrotic tissue that required debride-
ment, management of critical coloni-
sation, or bioburden reduction. All
participating patients provided written
informed consent for their participation.
A brief patient medical history was
recorded, a suitable wound identified,
and baseline measurements and
photographs taken. Wounds were
cleansed as required before the app-
lication of the first dressing. Mesitran
Ointment (or Mesitran Ointment S)
was applied in accordance with the
manufacturer’s instructions. A suitable
secondary dressing was then applied,
based on the needs of the wound, and
in accordance with the requirements
of the clinical investigator. All
information relating to the case study
evaluations was documented on specific
case report forms (Figure 1) designed
for this study and collated into an elec-
tronic database. Photographs were taken
throughout the treatment of each of
the patients at appropriate time points.

Wound Assessment
Date of Assessment: _ _ /_ _ / 2005.
Wound Size: Length ____ cm x Width ____ cm x Depth ____ cm

Reason for ending study Wound progress Wound description (%)

3 week evaluation complete Healed Epithelium
Wound healed Marked improvement Granulation
Patient withdrawn Some Improvement Slough
Reason for withdrawal: Stable Eschar
_______________________________ Some deterioration Fibrin
_______________________________ Marked deterioration Other

Surrounding skin Pain between dressing changes

Significant improvement No pain
Improvement Slight
Stable Moderate
Deterioration Deterioration

Pain at dressing change Dressing odour Exudate handling

No pain None Excellent
Slight Slight odour Good
Moderate Malodorous Moderate
Very malodorous Poor

Flexibility and/or adaptability Ease of application Patient comfort Ease of removal

Excellent Excellent Excellent Excellent
Good Good Good Good
Moderate Moderate Moderate Moderate
Poor Poor Poor Poor

Results

Figure 1. Example of case record form

Wounds UK 37
Case STUDY

Poor
Ease of Removal

Moderate
Good
Excellent
Poor
Patient Comfort

Moderate
Good
Excellent
Moderate
Application
Ease of

Good
Excellent
Moderate
Adaptability
Flexibility/

Good
Excellent
Moderate
Handling
Exudate

Good
Excellent
None
Odour

Slight
Malodourous
Pain at Change

None
Slight
Moderate
None
Pain Between
Changes

Slight
Moderate
Deterioration
Surrounding
Skin

Stable
Improvement
Deterioration
Progress
Wound

Stable
Improvement
% 0 10 20 30 40 50 60 70 80 90

Figure 2. Summary of case report evaluations

38 Wounds UK

The data collated from the case report
forms at each time point were evaluated
(Figure 2). The majority of the wounds
showed improvement (70%) or were
stable (8%), with only 20% showing
some form of deterioration. Photographs
of examples of these wounds were also
taken, and these demonstrate the
debriding action of the ointments in a
variety of different wound types (Figures
4–8). The clinical observations correlate
with the reports in the scientific literature
which demonstrate that honey-based
dressings can be used to enhance the
healing process (Dunford, 2005; Molan
and Betts, 2004) and effectively debride
wounds (Dunford and Hanano, 2004;
Alcaraz and Kelly, 2002; Molan, 2002;
Ahmed et al, 2003; Staunton et al,
2005).
The results demonstrate that the
surrounding skin of the wounds treated
with the Mesitran ointments was generally
stable (57%), with some skin showing
improvement (22%) (Figure 2). These
observations may have been due to
the effect of the honey in the Mesitran
ointments causing a reduction in the
propensity for adjacent tissue macer-
ation, an effect which has been reported
in the literature for honey and honey-
based dressings (Molan, 2002). Other
components within Mesitran Ointment
have also been associated with
beneficial healing and skin improve-
ment, e.g. Aloe barbadensis (Chithra et
al, 1998; Somboonwong et al, 2000),
Calendula officinalis (Kartikeyan et al,
1990), vitamin C (Dickerson, 1993),
vitamin E (Ehrlich et al, 1972), and these
may have played a part in the results
presented.
The proportions of patients reporting
pain between, and at, dressing changes
were low (24% and 21% respectively).
This is not surprising, as the use of honey
to treat wounds has been previously
associated with a reduction in pain
(Molan, 2002; Van der Weyden, 2003).
The very low levels of pain reported
with Mesitran Ointment and Mesitran
Ointment S may be due to the fact
that they both contain relatively low
concentrations of honey (47% and
40% respectively); the level of honey
in the Mesitran ointments is lower than
that in many of the other conventional
honey-based dressings or the pure
honey that has been used previously to
treat wounds. Mesitran ointments may,
therefore, be associated with less of a
drawing effect and hence are less likely
to cause pain through the osmotic
movement of fluid. In addition, Mesitran
Ointment S was developed with a lower
concentration of honey specifically
for use on patients who may be more
sensitive to this type of honey wound
treatment.
A significant problem associated with
the majority of chronic wounds is mal-
odour, due to bacterial contamination
and the presence of necrotic non-viable
tissue that may be degrading (Bowler
et al, 1999).The results from this study
show that 85% of wounds did not
exhibit malodour. This is particularly
beneficial to patients who may feel
isolated by the social stigma of the
‘awful smells’ that are derived from
their wounds or their concurrent
Change in Wound Size vs. Time in Mesitran Treated Wounds
300
250
200
Wound Size %
150
100
50
0
0 10 20
Time (days)
Figure 3. Changes in wound size
Case STUDY
treatments (Bale, 2004). A number of
studies have shown to play a major
role in malodour reduction (Robson,
2003; Dunford and Hanano, 2004).
Feedback from nurses and patients about
the use of the ointments generated
positive results in terms of ease of
removal, ease of application, flexibility
and adaptability, Patient comfort and
exudate handling were generally report-
ed to be ‘good’ or ‘excellent’.
Wound length and breadth were meas-
ured at each dressing change. From this,
the wound area and percentage change
in size for each wound was calculated
(Figure 3). The changes in wound size
generally showed that the results were
favourable, with approximately 43% of
the wounds reduced in size, 36% stable
in relation to the previous time point,
and only 21% showing an increase in
size. These findings are consistent with
the scientific literature that indicates the
beneficial properties of a honey-based
treatment regimen (Molan, 2002).
Overview of Wound Size Change
INCREASED 21.4%
STABLE 35.7%
REDUCED 42.9%
30 40 50
Wounds UK 39
Case STUDY

Case Study 1
Sloughy wound on the outer aspect of right foot, pre- and post-treatment with Mesitran Ointment.

An elderly female patient with long-standing Parkinson’s disease and arthritis, presented with a sloughy wound (90% slough across the wound bed).The wound
was treated daily with Mesitran Ointment during the first week. Debridement was successful within one week of treatment.

Case Study 2
Lower leg venous leg ulcer pre- and post-treatment with Mesitran Ointment under Mesitran Border with compression therapy.

An elderly male patient presented with a long-standing venous ulcer of the lower leg, exhibiting light levels of exudate. The ulcer had previously healed but then
reoccurred, and consideration was given to skin grafting. The pictures depict a period of five months, whereby the ulcer showed a slow, but general, improvement in
granulation tissue formation and surrounding skin, following treatment with Mesitran Ointment and Mesitran Border. No malodour was associated with this
wound during treatment.

40 Wounds UK
 Case STUDY

Case Study 3
Ankle venous ulcer pre- and post-treatment with Mesitran Ointment on a foam dressing under compression therapy.

An elderly male patient presented with a long-standing left medial venous leg ulcer that had failed to heal. The wound exhibited light levels of wound exudate.
As can be seen from the photographs, the wound demonstrated an increase in epithelial and granulation tissue over a three-week treatment period with Mesitran
Ointment. No malodour was associated with the wound; nor was pain an issue with the treatment.

Case Study 4
Sacral deep cavity wound pre- and post-treatment with Mesitran Ointment S under a foam dressing.

An elderly, immobile female patient with arthritis presented with a wound exhibiting light levels of exudate. Initially, the wound was associated with slight malodour.
This was a difficult wound to treat due to its location. Mesitran Ointment S was used to fill the cavity, and a foam dressing applied to retain the ointment within
the wound. After treatment with Mesitran Ointment S, the slough became loose and was removed from the wound, with granulation tissue observed. Malodour was
significantly reduced and no pain associated with the dressing regime was reported.

Wounds UK 41
Case STUDY
Case Study 5
Venous leg ulcer pre-, during and post-treatment with Mesitran Ointment under compression.
An elderly male patient presented with lower leg venous ulceration, with the added problem of a variety of pathogenic microbial organisms colonising the wound.
The debridement response with Mesitran Ointment was slow but steady, resulting in slough removal and progression towards healing. No antibiotics were used to
treat the wound, and no pain or malodour was associated with the wound during treatment.
Conclusion
Overall, the Mesitran Ointment and
Mesitran Ointment S demonstrated
positive results, especially in terms of de-
bridement and preparation of the wound
bed. Wound malodour appeared to be
reduced, or not present, in the majority
of the cases treated, thus impacting
favourably on the patient’s quality of life.
Pain was not deemed to be an issue with
the majority of patients treated with the
Mesitran products. The physical handling,
application, and removal of the Mesitran
dressings was reported to be good or
excellent by nurses and patients.
Declaration of interest
This study was funded by Medlock
Medical.
References
Ahmed AK, Hoekstra MJ, Hage JJ, Karim RB
(2003) Honey-medicated dressing: transformation
of an ancient remedy into modern therapy. Annals
of Plastic Surgery 50 (2):143-7; discussion 147-8
Alcaraz A, Kelly J ( 2002) Treatment of an infected
leg ulcer with honey dressings. British Journal
of Nursing 11 (13): 859 – 60, 862, 864-6
Bale S, Tebbie N, Price P (2004) A topical metro-
nidazole gel used to treat malodorous wounds.
British Journal of Nursing 13 (11): S4-S11
42 Wounds UK
Beitz JM. (2005) Wound debridement: thera-
peutic options and care considerations. Nursing
Clinics of North America 40 (2): 233-49
Bowler PG, Davies BJ, Jones SA (1999) Microbial
involvement in chronic wound malodour.
Journal of Wound Care 8 (5): 216-8
Chithra P, Sajithlal GB, Chandrakasan G (1998)
Influence of aloe vera on collagen turnover in
healing of dermal wounds in rats. Indian Journal
of Experimental Biology 36 (9): 896-901
Davies CE, Turton G, Woolfrey G, Elley R,
Taylor M (2005) Exploring debridement options
for chronic venous leg ulcers. British Journal of
Nursing 14 (7): 393-7
Dickerson JWT (1993) Ascorbic acid, zinc and
wound healing. Journal of Wound Care 2 (6): 350-3
Dunford C (2005) The use of honey-derived
dressings to promote effective wound
management. Professional Nursing 20 (8): 35-8
Dunford C, Hanano R (2004) Acceptability to
patients of a honey dressing for non-healing
venous leg ulcers. Journal of Wound Care 123
(5): 193-7
Efem SE (1993) Recent advances in the
management of Fournier’s gangrene: preliminary
observations. Surgery 113(2): 200-4
Ehrlich PH, Tarver H, Hunt TK (1972) Inhibitory
effects of vitamin E on collagen synthesis and
wound repair. Annals of Surgery 175 (2): 235-40
Kartikeyan S, Chaturvedi RM, Narkar SV (1990)
The effect of Calendula on trophic ulcers.
Leprosy Review 61: 399
Molan PC (2002) Re-introducing honey in the
management of wounds and ulcers – theory
and practice. Ostomy Wound Management 48
(11): 28-40
Molan PC, Betts JA (2004) Clinical usage of
honey as a wound dressing: an update. Journal
of Wound Care 13 (9): 353-6
Robson V (2003) Leptospermum honey used
as a debriding agent. Nurse 2 (11): 66–8
Staunton CJ, Halliday LC, Garcia KD (2005)
The use of honey as a topical dressing to treat a
large, devitalized wound in a stumptail macaque
(Macaca arctoides). Contemporary Topics in
Laboratory Animal Science 44 (4): 43-5
Somboonwong J, Jariyapongskui A,
Thanamittramanee S, Patumraj S (2000)
Therapeutic effects of aloe vera on cutaneous
micro-circulation and wound healing in second
degree burn model in rats. Journal of the
Medical Association of Thailand 83: 417-25
Subrahmanyam (1998) A prospective
randomised clinical and histological study of
superficial burn wound healing with honey
and silver sulphadiazine. Burns 22 (6): 331-3
Van der Weyden EA (2003) The use of honey
for the treatment of two patients with pressure
ulcers. British Journal of Community Nursing 8
(12): S14-S20
White R,Molan P(2005)Asummary of published
clinical research on honey in wound manage-
ment. In: White R, Cooper R, Molan P, Eds.
Honey: A modern wound management product.
Wounds UK Publishing, Aberdeen: 130-42
 Product FOCUS

Mesitran Product Focus

Mesitran is a range of honey-containing wound dressings consisting of Mesitran Ointment, Mesitran Ointment S, Mesitran,
Mesitran Border and Mesitran Mesh. These dressings were originally developed by Triticum Exploitatie (Maastricht,
Netherlands). The founder of the Triticum company, Dr. Theo Postmes, spent many years researching the therapeutic
properties of honey. He conducted several studies which demonstrated that honey was beneficial to the healing
of wounds (Postmes et al, 1993; Postmes et al, 1995; Postmes and Vandeputte, 1999). In 2000, several patents were
established and products were prepared for the professional healthcare market. The honey-containing dressings
were launched in 2002 and sold in Belgium as L-Mesitran. In 2004, Medlock Medical (Oldham, UK) acquired the rights
to market Mesitran products in the United Kingdom and subsequently launched the full range in 2005. All products
within the Mesitran range (Table 1; Figure 1) are currently listed in the Appliances section (Part IX) of the Drug Tariff and
have been reimbursable against National Health Service prescriptions since August 1st 2005.

Mark Rippon PhD, Philip Davies BSc (Hons)

The Mesitran range is made up of Mesitran Ointment contains medical

KEY WORDS three categories of product: grade honey (47%), lanolin, sunflower
• Ointment – Mesitran Ointment oil, cod liver oil, Calendula officinalis,
Mesitran Debridement
and Mesitran Ointment S Aloe barbadensis, vitamins C & E, and
Ointment Cleansing • Sheet Hydrogel Dressing – zinc oxide.
Dressing Fluid absorption Mesitran and Mesitran Border
Honey Fluid retention • Primary Wound Contact Layer – Mesitran Ointment S contains medical
Chronic wound Mesitran Mesh grade honey (40%), lanolin, vitamins
C & E, and polyethylene glycol.

Mesitran Ointment and Mesitran Manufacturer’s Claims

Table 1 Ointment S • Cleanse and debride wounds
Mesitran range of • Reduce malodour
honey-containing dressings Key Features • Provide a moist wound environment
These ointments are used for wound
Ointments cleansing and debridement, to facilitate Applications
Name Size the removal of necrotic and sloughy Mesitran Ointment is a honey-based
Mesitran Ointment 15g tissue from the surface of the wound. wound ointment, indicated for use in the
Mesitran Ointment 50g The purpose of this is to provide a early stage treatment of chronic wounds
Mesitran Ointment S 15g clean wound bed from which healing (e.g. for debridement) such as venous
can take place. The ointments can be leg ulcers, first- and second-degree
used to debride virtually all wound burns, and diabetic ulcers.
Dressings types including those associated with
Name Size dry, hard eschar (e.g. black heels)
Mesitran 10cm x 10cm and wet, sloughy material (e.g. venous Key Points
Mesitran 20cm x 15cm leg ulcers).
Mesitran 17.5cm x 10cm Mesitran Ointment and Mesitran
Composition
Mesitran Border 10cm x 10cm Ointment S
The Mesitran ointments, in addition
Mesitran Border (shaped) 15cm x 13cm to containing honey, have been • Debridement
Mesitran Border 15cm x 15cm carefully formulated with other natural • Malodour control
Mesitran Mesh 10cm x 10cm components that, historically, have
been shown to have beneficial effects Mesitran and Mesitran Border
on healing. The honey used in • Exudate management
Mesitran products is subjected to
Mark Rippon PhD (Regulatory Affairs Manager) and Mesitran Mesh
Philip Davies BSc (Hons) (Medical Information Manager), physico-chemical testing and
Medlock Medical Limited, Tubiton House, Medlock Street, sterilisation. It is therefore referred to • Primary wound contact layer
Oldham, OL1 3HS. as medical grade honey.

Wounds UK 43
Product FOCUS
Figure 1. Mesitran range of honey-containing wound dressings
Mesitran Ointment S is a wound
ointment that contains less honey than
Mesitran Ointment. It is also indicated
for use in the early stage treatment
of chronic wounds and, because of its
lower honey content, it is generally used
on patients who are unable to tolerate
the drawing effect of Mesitran Ointment.
Cleansing and Debriding
Debridement is the removal of
devitalised tissue, eschar or debris from
a wound. Although these can be
removed by natural processes, it is
generally recognised that large quantities
of dead tissue will delay healing and may
provide a focus for infection (Bradley et
al, 1999), thus the intervention and
removal of this tissue by debridement
is now an accepted principle of good
wound care. Debridement is seen as
a requirement for the preparation of a
clean wound bed and a prerequisite for
healing to begin (Beitz, 2005; Davies
et al, 2005). There are a number of
different methods of debridement
(surgical, chemical, autolytic, mechanical
and bio-surgical), all used with varying
degrees of success.
Honey has been used successfully for
many years in the treatment of wounds,
with references to its use dating back as
far as Ancient Egyptian and Roman times.
It is well established in folklore as a
44 Wounds UK
‘remedy’ for all sorts of wound types of references relating to the reduction
and skin disorders (Zaghloul et al, 2001). or elimination of malodour post-
A particular benefit attributed to the use application of honey or honey dressings
of honey in the treatment of wounds
is that it is very effective as a debriding
and cleansing agent.This is supported by
numerous recent clinical studies in which
successful debridement was achieved
with honey (Cavanagh et al, 1970;
Armon, 1980; Branicki, 1981; Efem,
1988; Subrahmanyam, 1991; Efem,
1993; Subrahmanyam, 1993; Dunford
et al, 2000; Alcaraz and Kelly, 2002;
Molan, 2002; Ahmed, 2003; Staunton
et al, 2005).
Clinical case studies have demonstrated
that both Mesitran Ointment and
Mesitran Ointment S can be used to
successfully debride a variety of
wounds such as black heels, venous
ulcers, lesions associated with meningo-
coccal septicaemia (Figure 2), surgical
wounds, dehisced amputation lesions
and infected wounds (Gray et al, 2005).
Reducing Malodour
Wound malodour arises as a conse-
quence of tissue necrosis and can be
associated with infected wounds
involving mixed microbial populations.
(Bowler et al, 1999). Malodour can be
very distressing for patients, affecting Figure 2. Wound demonstrating black
their social interactions and behaviour eschar pre- and post-debridement with
(Bale et al, 2004). There are a number Mesitran Ointment

(Kingsley, 2001; Alcaraz and Kelly, 2002;
Dunford & Hanano, 2004). Case study
evaluations have consistently highlighted
Mesitran’s effect on reducing or removing
completely malodour, resulting in better
quality of life for patients (Gray et al,
2005).
The ability of honey to combat wound
malodour is believed to be principally
due to it acting against the primary source
of the malodour: the bacteria. A number
of authors have demonstrated anti-
bacterial effects of honey against wound
pathogens (Cooper, 2005), including
anaerobic bacteria (Efem et al, 1992;
Elbagoury and Rasmy,1993). Mesitran
has also been shown to be effective
against a variety of wound pathogens,
which may contribute to its malodour-
reducing properties in chronic wounds
(Vandeputte and Van Waeyenberge,
2003).
Providing Moist Wound Environments
There is evidence in the literature that
supports the claim that honey provides
a moist wound healing environment
which is beneficial to the healing process
(Molan 2001; Molan, 2002). Mesitran
Ointment and Mesitran Ointment S
both contain medical grade honey that
will aid in the formation of a moist
interface between the dressing and the
wound. Case study evidence supports
the claims that the Mesitran ointments
provide optimum moist wound environ-
ments, in that no wounds were seen
to have dried out when the ointments
were used (Gray et al, 2005).
Mesitran and Mesitran Border Sheet
Hydrogel Dressings
Key Features
Mesitran and Mesitran Border (Figure 3)
may be used alone as primary wound
dressings. They possess a number of
properties that benefit the healing
process: fluid absorption characteristics
enabling the treatment of wounds with
light, moderate or heavy exudation; the
ability to lock exudate within their
matrices, thus helping to prevent tissue
maceration of wounds and the surround-
ing normal skin; the ability to create
moist wound healing environments;
and bacterial barrier properties.
Composition
Mesitran and Mesitran Border are sterile,
semi-permeable sheet wound dressings
that contain medical grade honey (30%).
They are formulated with a honey gel
of acrylic polymers and water: the gel is
covered with a polyurethane film.
Manufacturer’s Claims
• Manage wound exudate
• Provide moist wound environments
• Bacterial barrier
Figure 3. Mesitran Border Being Applied
to Forearm
Applications
The Mesitran hydrogel dressings are
used on wounds at the later stages of
healing (showing granulation tissue,
early re-epithelialisation). They can be
used primarily for the management
of wound exudate in both acute and
chronic wounds such as: superficial
wounds, first- and second-degree burns;
pressure ulcers; venous and arterial
ulcers; diabetic ulcers; donor sites; post-
operative wounds and other wounds
caused by trauma.
Managing Wound Exudate
Acute wound exudate results from the
extravasation of serous fluid and contains
a variety of cells (e.g. neutrophils,
lymphocytes and macrophages), plasma
proteins (including albumin, globulin,
fibrinogen and gamma globulins),
enzymes (such as proteases), growth
factors, inflammatory mediators, and
matrix molecules (Baker and Leaper,
2000). It has been shown that acute
wound fluid can stimulate the growth of
cells involved in the healing process.
Conversely, chronic wound fluid, which
differs from that associated with acute
Product FOCUS
wounds, has been demonstrated to have
an adverse effect on these cells and
the wound healing process in general.
It is has been shown that this adverse
effect can in part be attributed to exces-
sive levels of proteases and inflammatory
mediators, leading to an excessive and
prolonged inflammatory response and
local degradation of tissue (Drinkwater
et al, 2002).
It is imperative, therefore, in the treat-
ment of chronic wounds to provide an
optimum moist wound healing environ-
ment and achieve the delicate balance
between an excess of wound exudate
– that may lead to maceration – and the
drying out of the wound, which could
lead to cell and tissue death. In an attempt
to achieve this balance, nurses can use
a variety of treatments such as negative
pressure vacuum systems or the more
traditional approach of applying absorp-
tive dressings.There are a large variety of
such absorptive dressings currently avail-
able, including foams, hydrofibres and
hydrocolloids.These dressings have been
designed to manage various exudate
loads, from light to moderate to heavy.
The Mesitran dressings can be used in
the management of exudating wounds.
Laboratory testing has shown that
Mesitran dressings can handle fluid loads
across the range, up to and including
wounds with heavy levels of exudate
(Figures 4 and 5). Mesitran dressings,
therefore, compare favourably with
highly absorptive dressings such as foams
and hydrofibres.
The ability of Mesitran dressings to lock
away fluid within their matrices has
implications for reducing the risk of tissue
maceration resulting from exudate
leaking from dressings, especially if used
under compression.
Providing Moist Wound Environments
It has been shown that honey alone can
be used to maintain a moist wound
environment and can be beneficial to
healing (Molan, 2001; Molan, 2002).
The medical grade honey content of the
Mesitran sheet hydrogel dressings will
give them a ‘head start’ in maintaining
an optimum environment for healing.
Wounds UK 45
Product FOCUS

MV loss g/10cm2 Absorbency g/10cm2 Total g/10cm2

14
Fluid Handling Capability

12

10

0
24hrs 48hrs 72hrs

Figure 4. Fluid uptake of Mesitran at 24, 48 and 72 hours. Trend line shows a linear uptake of fluid over the period of time measured.

100

90

80
% Fluid Retained (sd)

70

60

50

40

30

20

10

0
Allevyn Kaltostat Aquacel Mesitran

Figure 5. Percentage fluid retained in Mesitran dressings post-application of static and rolling pressures.

46 Wounds UK

Dressings need to be able to maintain
the balance between moisture vapour
transmission and fluid absorption, such
that they do not allow wounds to dry
out or become too wet, leading to scab
formation and maceration respectively.
The results of laboratory studies show
that the Mesitran dressings maintained
a high level of fluid absorption through-
out the 72-hour testing period (Figure 4).
The data support the positioning of
Mesitran and Mesitran Border alongside
other dressings associated with high
absorptive capabilities such as foams and
alginates. As with most dressings of this
type, the interface between the dressing
and the wound surface consists of a
moist micro-environment conducive to
re-epithelialisation and the formation of
granulation tissue.
Clinical case study reports indicate that
the moist wound interface, noted during
dressing changes, aids removal of the
Mesitran dressings. (Data on file,
Medlock Medical). It has also been
reported that the transparency of the
dressings allows visualisation and meas-
urement of wounds without the need
to remove them, thus avoiding the risk
of disrupting the healing process.
Figure 6. Mesitran dressing in situ, allowing
visualisation of ulcer
Bacterial Barrier
There is a plethora of information relating
to the antibacterial properties of honey
and honey-containing dressings (Lusby
et al, 2005; French et al, 2005).
Laboratory tests undertaken at the
University of Wales (Cardiff) and by the
Triticum company have shown log
reductions of Escherichia coli, Pseudo-
monas aeruginosa and Staphylococcus
aureus when challenged with Mesitran
dressings (Data on file, Medlock Medical,
Oldham, UK).
Mesitran Mesh
Key Features
Mesitran Mesh is a multi-purpose non-
adherent wound contact layer providing
some wound exudate absorption and
retention.
Composition
Mesitran Mesh (figures 7 and 8)
contains 20% medical grade honey in
a gel of acryl polymers and water on an
open weave polyester net. It is indicated
for use in a variety of acute and chronic
wounds in conjunction with a secondary
dressing, and as such can be combined
with Mesitran ointments and sheet
hydrogel dressings.
Figure 7. Mesitran Mesh being applied to
forearm
Figure 8 Mesitran Mesh in situ
Product FOCUS
Manufacturer’s Claims
• Forms a conformable, soft,
soothing gel as a primary wound
contact dressing
• Provides moist wound environments
Forms a conformable, soft, soothing gel as a primary
wound contact dressing
Mesitran Mesh is highly absorbent, and
forms a gel on contact with wound
exudate. With the same characteristics
as the sheet hydrogel dressings, it does
not wick fluid away but retains it within
its matrix. To date, clinical studies have
shown that it has been useful in treating
skin tears, for use as a primary wound
contact layer and for packing cavity
wounds.
Maintains a moist wound environment
The absorbent and gelling characteristics
of Mesitran Mesh, if used in conjunction
with an occlusive dressing, will help
maintain a moist wound environment.
This effect is enhanced by the ability of
honey to promote moist environments,
as described earlier.
Conclusion
In Mesitran, health professionals have
access to a range of prescribable honey
-based ointments and dressings. The
Mesitran ointments possess significant
debriding, cleansing and deodorising
properties. The Mesitran dressings are
capable of handling significant levels of
exudate and help to maintain a moist
wound environment conducive to
healing. The Mesitran hydrogel sheets
also act as bacterial barriers.
Wounds UK 47
Product FOCUS

References
Ahmed AK, Hoekstra MJ, Hage JJ, Karim RB
(2003) Honey-medicated dressing:
transformation of an ancient remedy into modern
therapy. Annals of Plastic Surgery 50 (2): 143-7
Alcaraz A, Kelly J (2002) Treatment of an
infected leg ulcer with honey dressings. British
Journal of Nursing 11 (13): 859–60, 862, 864-6
Armon PJ (1980) The use of honey in the
treatment of infected wounds. Tropical Doctor
10 (2): 91
Baker EA, Leaper DJ (2000) Proteinases, their
inhibitors, and cytokine profiles in acute
wound fluid. Wound Repair and Regeneration 8
(5):392-8
Bale S, Tebbie N, Price P (2004) A topical
metronidazole gel used to treat malodorous
wounds. British Journal of Nursing 13 (11): S4-
S11
Beitz JM (2005) Wound debridement:
therapeutic options and care considerations.
Nursing Clinics of North America 40 (2):233-49
Bowler PG, Davies BJ, Jones SA (1999)
Microbial involvement in chronic wound
malodour. Journal of Wound Care 8 (5):216-8
Bradley M, Cullum N. Sheldon T (1999) The
debridement of chronic wounds: a systematic
review. Health Technology Assessment 3 (17 Pt
1): iii-iv, 1-78
Dunford CE, Hanano R (2004) Acceptability
to patients of a honey dressing for non-healing
venous leg ulcers. Journal of Wound Care 13
(5): 193-7
Efem SEE (1988) Clinical observations on the
wound healing properties of honey. British
Journal of Surgery 75: 679-81
Efem SEE (1993) Recent advances in the
management of Fournier’s gangrene:
preliminary observations. Surgery 113: 200-4
Efem SE, Udoh KT, Iwara CI (1992) The
antimicrobial spectrum of honey and its
clinical significance. Infection 20 (4): 227-9
Elbagoury EF, Rasmy S (1993) Antibacterial
action of natural honey on anaerobic
bacteroides. Egyptian Dental Journal 39
(1):381-6
French VM, Cooper RA, Molan PC (2005) The
antibacterial activity of honey against
coagulase-negative staphylococci. Journal of
Antimicrobial Chemotherapy 56 (1): 228-31
Gray D, Stephen-Haynes J, Cutting K (2005)
Clinical Case Studies Using Mesitran
Ointment. Poster presentation, Tissue Viability
Society Meeting and 8th European Pressure
Ulcer Advisory Panel Open Meeting Aberdeen,
Scotland, May 2005
Kingsley A (2001) The use of honey in the
treatment of infected wounds: case studies.
British Journal of Nursing 10 (22): S13- S20
Staunton CJ, Halliday LC, Garcia KD (2005)
The use of honey as a topical dressing to treat a
large, devitalized wound in a stumptail macaque
(Macaca arctoides). Contemporary Topics in
Laboratory and Animal Science 44 (4): 43-5
Subrahmanyam M (1991) Topical application
of honey in treatment of burns. British Journal
of Surgery 78: 497-8
Subrahmanyam M (1993) Honey impregnated
gauze versus polyurethane film (OpSite®) in
the treatment of burns – a prospective
randomised study. British Journal of Plastic
Surgery 46: 322-3
Vandeputte J, Van Waeyenberge PH (2003)
Clinical evaluation of L-Mesitran – a honey-
based wound ointment. European Wound
Management Association Journal 3 (2): 8-11
Zaghloul AA, el-Shattawy HH, Kassem AA,
Ibrahim EA, Reddy IK, Khan MA (2001)
Honey, a prospective antibiotic: extraction,
formulation, and stability Pharmazie 56
(8):643-7

Branicki FJ (1981) Surgery in western Kenya.
Annals of the Royal College of Surgeons of England
63 (5):348-52
Cavanagh D, Beazley J, Ostapowicz F (1970)
Radical operation for carcinoma of the vulva.
A new approach to wound healing. Journal of
Obstetrics and Gynaecology of the British
Commonwealth 77 (11):1037-40
Cooper R (2005) The antimicrobial activity of
honey. In: White R, Cooper R, Molan P, eds.
Honey : A modern wound management product.
Wounds UK Publishing, Aberdeen: 24 - 32
Davies CE, Turton G, Woolfrey G, Elley R,
Taylor M (2005) Exploring debridement
options for chronic venous leg ulcers. British
Journal of Nursing 14 (7):393-7
Drinkwater SL, Smith A, Burnand KG (2002)
What can wound fluids tell us about the venous
ulcer microenvironment? International Journal
of Lower Extremity Wounds 1 (3):184-90
Dunford C, Cooper R, Molan P, White R
(2000) The use of honey in wound
management. Nursing Standard 15 (11): 63-8
Lusby PE, Coombes AL, Wilkinson JM (2005)
Bactericidal activity of different honeys against
pathogenic bacteria. Archives of Medical
Research 36 (5): 464-467
Molan PC (2001) Potential of honey in the
treatment of wounds and burns. American
Journal of Clinical Dermatology 2 (1):13-9
Molan PC (2002) Re-introducing honey in the
management of wounds and ulcers – theory
and practice. Ostomy/Wound Management 48
(11):28-40
Postmes T, van den Bogaard AE, Hazen M
(1993) Honey for wounds, ulcers, and skin
graft preservation. Lancet 341 (8847): 756-7
Postmes T, van den Bogaard AE, Hazen M
(1995) The sterilization of honey with cobalt
60 gamma radiation: a study of honey spiked
with spores of Clostridium botulinum and
Bacillus subtilis. Experientia 51 (9-10): 986-9
Postmes T, Vandeputte J (1999) Recombinant
growth factors or honey? Burns 25 (7): 676-8
Robson V. 2003
Leptospermum honey used as a debriding
agent Nurse 2(11): 66-8

48 Wounds UK
Technical INFORMATION

A Review of the Physical

Performance Characteristics
of Honey-based Wound
Dressings and Ointments
The Mesitran (Medlock Medical, UK) range of honey-based wound dressings includes a variety of
presentations and formulations designed for different wound conditions. This paper provides information
relating to the physical performance characteristics of these dressings to help identify the wounds on which
the dressings can be used to best effect. In order to aid in the positioning of the products by the nurse, a
comparison with data from referenced sources of products already available in the market place is provided.

Mark Rippon PhD, Darren Jones

KEY WORDS
Mesitran
Honey
Wounds
Debridement
Deodourisation
Fluid Handling
Introduction
Many modern wound care dressings
attempt to heal rather than merely
manage symptoms. These dressings fall
into the category of ‘active’ wound
dressings that keep the wound moist,
yet allows it to breathe. They do not
require frequent changing like dry, gauze
dressings, as they absorb exudate
without drying out the wound and
provide an optimal (moist) environment
for healing to take place (Jones, 2005).
A variety of dressings are currently
available in the market place in the UK
making it difficult for the nurse to identify
products that will fully meet the needs to the external environment; fluid
of the patient. In making the decision absorption, i.e. the cability of the
about choice of dressing, the nurse will dressing to absorb and retain moisture;
take into consideration many factors. and finally; the total fluid handling
Of importance will be the physical capacity, which takes into account both
characteristics of dressings and the way of these parameters and has a bearing
in which they interact or control the on the wear time of the dressing,
environment of the wound. particularly so on a highly exuding wound.
The requirement to manage exudates
Characteristics of the dressings that have and prevent maceration of wound and
clinical relevance are the Moisture adjacent tissue is a high priority.
Vapour Transmission rate (MVTR), i.e.
the evaporation of a proportion of the This article provides data, to help
aqueous component of wound exudate identify the wounds on which the
through the outer surface of the dressing range of Mesitran dressing can be
Key Points
Mesitran Dressings
• Light to heavy exudate management properties
• Lock fluid away within dressing matrix, potential reduction in tissue maceration
Mesitran Ointment /Mesitran Ointment S
• Excellent debridement properties for wound bed preparation
• Consistant malodour control

Mesitran Mesh
Mark Rippon PhD (Regulatory Affairs Manager) and
• Gelling wound contact layer, allows for ease of removal from wound bed
Darren Jones (Laboratory Team Leader), Medlock Medical,
Tubiton House, Medlock St. Oldham OL1 3HS

50 Wounds UK

used to best effect. In order to aid in
the positioning of the product by the
nurse, a comparison with data of some
products already available in the market
place is presented.
The Mesitran range of dressings consists
of: Mesitran Ointment, Mesitran
Ointment S, Mesitran, Mesitran Border
and Mesitran Mesh.
Methods
Mesitran Dressings and Mesitran Mesh
were analysed by Surgical Materials
Testing Laboratory, Bridgend, UK (SMTL)
according to its standard procedures
outlined in Table 1.
Fluid Retention under pressure testing
The fluid retention under pressure of
a dressing is its ability to retain an
added amount of liquid under external
pressure. A static weight and a dynamic
weight are used to simulate movements
in bed, chair etc. The following method
was undertaken in-house to evaluate
fluid retention in the dressings.
A dressing sample (5cm x 5cm) was
placed into a clean dry Petri dish and
Moisture Vapour Loss g /10cm2
14
12
Total Fluid Handling
10
0
24hrs 48hrs
Hydrocolloid*
Figure 1. Fluid Handling Performances.
Technical INFORMATION
Table 1
Surgical Materials Testing Laboratory Protocols
Protocol Title Protocol Ref No.
Moisture Vapour Transmission Rate from Dressings by Electronic Capture Method TM-8
Fluid Handling Properties of Wound Management Dressings TM–65
Absorbance by wicking TM-1
Absorbency (Petri dish Method) TM-101
Dispersion Characteristics of Hydrogel Dressings TM-116
Fluid Affinity of Amorphous Hydrogel Drssings TM-238
pH of Liquid Hydrogels TM-115
Mesitran Dressings and Mesitran Mesh were analysed by SMTL according to their standard
procedures outlined above.
onto a balance and tared. Saline solution weight applied for one hour. After
(5 g) was added to the dish and left for one, hour the weight was removed
two hours to allow absorption into and the sample rolled with a 2 kg
the dressing. After two hours, fluid not roller for 15 minutes. The amount
absorbed was weighed and subtracted of fluid retained in the dressing was
from the original weight to give the calculated after the roller and static
actual weight of the fluid absorbed. pressure treatment.
A clean dry Petri dish was weighed
and a wire tray placed into the centre Results
of the Petri dish. The dressing sample
Mesitran Dressings (10 x 10 cm)
was placed onto the wire tray (wound
contact side down) and a static 2.7 kg – Fluid Handling
Absorbency g /10cm2
72hrs 24hrs 48hrs 72hrs 24hrs 48hrs 72hrs
Foam* Hydrogel*
*Data on File, Medlock Medical.
Wounds UK 51
Technical INFORMATION

The data relating to the mean moisture

vapour loss, absorbency and fluid han- Table 2
dling of the Mesitran dressings at 24, 48 Moisture Vapour Transmission Rate Of Mesitran Dressing (10 x 10cm)
and 72 hrs are presented in Figure1. A
comparison of absorbency data from Dressing Maximum MVTR (g/m2/24hrs)
examples of a foam (Allevyn, Smith and
Nephew, UK), hydrocolloid (Comfeel Mesitran 1505 1520 1961
Plus, Coloplast, Denmark) and sheet Run 1 Run 2 Run 3
hydrogel (Mesitran) is presented. These
results show that the Mesitran dressings
have a high overall fluid handling capability
over the period tested. From this data, 45
it is apparent that the dressings can
be used across a range of low to highly
exudating wounds. 40
% Fluid Lost from Dressing

– Moisture Vapour Transmission Rate 35

Table 2 shows the MVTR of Mesitran

30
10 x 10 cm dressing over a period of
24 hours.
25
– Fluid Retention in dressing
20
The results of the test evaluating the
amount of fluid retained in the
15
dressings after being subjected to a
static and rolling pressure are presented
in Figure 2. They demonstrate that the 10
foam, alginate and hydrofibre dressings
released 10.1, 38.1 and 17.9% 5
respectively of the original volume of
fluid absorbed when under pressure.
This is compared with the volume 0
released by the Mesitran dressing of Allevyn Kaltostat Aquacel Mesitran
only 0.36% of the original volume of
fluid absorbed by the dressing. Figure 2. Fluid Retention in Dressings.

Mesitran Mesh (10 cm x 10 cm)

Table 3
– Absorbency by Wicking
Absorbency Wicking of Mesitran Mesh
Table 3 demonstrates the ability of the Dressing Mean Absorbency g (s.d.) Mean Absorbency g/cm width (s.d.)
dressing to wick away fluid from the
surface of the wound.
Mesitran Mesh 1.33 (0.167) 0.13 (0.0017)
Notes from the Test Report

“The dressing did not appear Table 4

to wick the fluid, rather Absorbtion – Petri Dish method
the portion of the dressing
Dressing Mean Weight of Solution retained/10cm2 g (s.d.)
submerged in the solution
absorbed/swelled” Mesitran Mesh 14.39 (0.367)

52 Wounds UK
 Technical INFORMATION

– Absorption – Petri Dish Method

Table 5
Table 4 demonstrates the fluid Fluid Absorbtion – Mesitran Ointment
absorption using a Petri dish rather than
the Standard method which could not Product Agar Concentration Mean % Decrease in Ointment Weight (s.d.)
be applied to the Mesitran Mesh.
Mesitran 2% 0.48 (0.177)
Ointments
– Fluid Affinity

Fluid affinity tests are designed to

demonstrate any fluid donation or Table 6
absorption, a feature often related to Fluid Donation – Mesitran Ointment
amorphous wound hydrogels and
Product Gelatin Concentration Mean % Decrease in Ointment Weight (s.d.)
thought to be an important performance
parameter. The ointment in both the
agar and gelatin fluid affinity tests Mesitran 35% 0.94 (0.208)
exhibited a slight decrease in weight
(see Tables 5 and 6 respectively), but
this decrease was thought to be due to
the variances of the test method and
not a direct donation of fluid.
Table 7
pH evaluation
Generally fluid affinity of hydrogel Dressing Mean pH (s.d.)
dressings are classified according to their
ability to either donate or absorb fluid, (0.275)
Mesitran Ointment 5.47
in terms of the percentage.

– Dispersion
Discussion wound exudate (Hansson, 1997;
The results of the testing showed that Ovens & Fairhurst, 2002). Controlling
Mesitran Dressings
the Mesitran Ointment did not dissolve the exudate element reduces the
in the test medium that contained – Fluid Handling effect of the other elements ultimately
142 mmol/litre of sodium ions and enhancing patient quality of life
2.5 mmol/litre of calcium ions. Rather, The fluid handling capacity of a wound (Vowden & Vowden, 2003).
the ointment separated into two layers. dressing is a laboratory measure of its
This may have implications for capacity to absorb exudate (simulated Wound exudate is very complex. It
evaluation of any of the “active” wound fluid), lose fluid by evaporation, consists of a variety of components
components of the ointment which and lock fluid away from the skin. including: water, salts, fatty acids,
may separate into either component. proteins carbohydrates, cells, bacteria
There are three primary elements that and their by-products (Mosely et al.,
have a direct impact upon the quality 2004). It may also contain growth
– pH
of life of patients with chronic wounds. factors and proteases that aid in the
These elements are pain, odour and control of new tissue growth and its
The pH of the dressings was measured
subsequent remodelling within the
as shown in Table 7.
newly formed tissue (Vogt et al, 1998).
Acute wound fluid bathes the wound
Notes from the Test Report and maintains it within the optimum
environment (physically and chemically)
“It is not possible to state whether the dressing complies for healing and has been shown to
stimulate fibroblasts and endothelial
as it is not an alginate dressing, but determined cells (Katz et al, 1991).
absorbency is high according to test method (12g/10cm2
Exudate from chronic wounds has been
or more are classified as of high absorbency).” shown to be disadvantageous to the
normal process of wound healing.

Wounds UK 53
Technical INFORMATION
It is thought that this is because chronic
wound fluid contains, for example, high
levels of proteases which lead to a
break down of wound and skin tissue
matrix components (Wysocki et al,
1999). Studies have also demonstrated
raised levels of inflammatory mediators
and free radicals which can lead to
excessive and prolonged localised
inflammation (Wlaschek M and
Scharffetter-Kochanek 2005). The
overall result is that chronic wound
exudate is detrimental to the normal
healing process and may cause tissue
maceration and damage (Mulder and
Vande Berg, 2002; Cutting 2003).
One of the main aims in the treatment
of a chronic wound with high levels of
exudate is its management with
appropriate absorptive dressings or
topical negative pressure. There are a
large variety of dressings currently
available, and they include foams,
hydrofibres and hydrocolloids. These
dressings have been designed to manage
exudate loads from light to heavy. In
the latter case some wounds have been
shown to generate levels of exudate in
the region of 50g/100cm2/day. This
relates to about 5ml of exudates per
10cm2 of wound tissue per day (Vowden
& Vowden, 2003).
The results from these studies (Figure 1)
have shown that Mesitran sheet
hydrogel dressings can handle up to
approximately 12 g/10cm2 fluid over
the 72hr period. The absorbency of
the dressing played the greater part of
the mechanism of fluid handling, as
opposed to MVTR which is generally
lower than that seen in the other
dressing types. It is thought therefore
Figure 3. Exudate Management by a Mesitran Dressing.
54 Wounds UK
that Mesitran dressings could be used
to manage loads across the range up to
and including wounds producing heavy
levels of exudate. Mesitran compared
favourably with high-absorptive
dressings such as hydrocolloids and
foams which demonstrated over the
same period in the region of 13 and
14 g/10cm2 fluid respectively over 72hrs.
Alternatively, with low to moderate
levels of wound exudates, these
dressings could be left in situ for longer
periods, thus being more cost-effective.
– Moisture Vapour Transmission Rates
The MVTR represents the amount of
moisture that passes through a
membrane such as a dressing during a
given time period (eg 24 hrs). The
higher the MVTR, the more effectively
moisture is removed, preventing the
accumulation of pools of moisture
under the membrane. The results in
Table 2 demonstrate the MVTR for
Mesitran to be in the region of 1500 –
1900 g/m2/24 hrs. This appears to be
mid-range for most dressings, the
upper level of 3000 g/m2/24 hrs being
stated in various manufacturers
literature as “high MVTR dressings”.
The fluid that is lost via MVTR is probably
only very small, and from a clinical
perspective, MVTR is subject to a wide
variety of external factors, temperature,
relative humidity and the presence of
multi-layer bandages. A recent study has
shown that film dressings with a high
MVTR reduce both the rate of blistering
and wound discharge, thereby
compensating for the additional expense
of using these types of dressings
(Cooker et al, 2005).
– Fluid Locking
A significant clinical benefit for the Mesitran
dressings is that absorbed fluid is locked
away within the matrix of the dressing
(Figure 3). Therefore, wound exudate is
not available to cause any further damage
or maceration to the wound or the sur-
rounding normal skin. This is very impor-
tant if the dressing is being used under
compression when exudate may leak
from the dressing on to surrounding skin
causing a sensitising reaction or tissue
breakdown (Hampton, 2004).
An additional factor in reducing tissue
maceration is the honey content of the
dressings. In Mesitran dressings, the
level of medical grade honey is 30%
and 20% for Mesitran dressings and
Mesh respectively. Studies have shown
that honey prevents tissue maceration,
although the mechanism by which it
does this is not yet clear (Molan, 2002;
Al-Waili, 2005; Kingsley, 2005).
Mesitran Mesh
Absorbency and Wicking
The results in Tables 3 and 4 shows
that the Mesitran Mesh was highly
absorbent, and gelled on contact with
the experimental fluid. To date clinical
studies undertaken by Medlock Medical
have shown that it has been used as a
primary wound contact layer, a dressing
used to pack cavity wounds and is useful
for treating skin tears. The dressing
gels upon contact with wound fluid
providing a moist wound contact that
does not wick fluid away but retains it
within its matrix, thus helping to prevent
any possibility of tissue maceration.
 Technical INFORMATION

Ointments

Fluid Affinity

The Mesitran Ointment falls into a

Class1a category according to SMTL
(Thomas et al, 2005) neither donating
nor absorbing fluid. According to this
categorisation it is a 1c category
hydrogel that donates fluid, but is less
well able to absorb fluid, is a good
debriding agent in that it provides fluid
to the tissue and eschar thus enhancing
autolytic debridement. However, we
are aware from clinical data on wounds PLA
SMIN MIN
PLAS
covered with dry eschar, that Mesitran
OGEN
ointment is an effective debriding agent
(Gray et al, 2005) despite these results.

Dead necrotic tissue whether it is dry-

black or wet-sloughy presents a real
hurdle to wound healing and it is
generally accepted that such eschar will
prevent or delay re-epithelialisation or
granulation tissue formation such that
the wound cannot progress through to
normal healing (Bradley et al,1999).
Debridement of this dead necrotic
tissue is now recognised as a necessary,
if not vital, component of the wound
care process, assisting in the
development of a clean wound bed,
from which normal healing can be
“kick started” (Beitz, 2005; Davies et
al, 2005). There are a variety of ways
that debridement may be undertaken:
surgical, enzymatic, wet to dry, bio-
surgical and autolytic (Steed, 2004).
Probably one of the most widely used
techniques is the relatively benign
enhancement of autolytic debridement
using wound hydrogels, especially on
hard necrotic lesions.
It is interesting to note that the laboratory
data presented here indicated that
Mesitran should not donate fluid to en-
hance autolytic debridement in the
clinical environment whereas the clinical
data to date (Gray et al., 2005) have
shown excellent debridement capabil-
ities of Mesitran Ointment on a variety
of different wound types. It is highly prob-
able therefore that the debridement
mechanism of the Mesitran Ointment
is acting in a completely different way
to that of simple autolytic debridement.
Figure 4. Proposed Mechanisms of Honey assisted debridement.
Two hypotheses have been proposed
(discussed below) for the debridement
mechanisms of honey, which may be
extended as a basis for Mesitran
Ointment debridement properties.
It has been hypothesised that honey
promotes conversion of inactive
plasminogen in the wound matrix to
the active form, plasmin (Molan, 2005),
a product of the lysis of plasminogen
(profibrinolysin) by plasminogen
activators. It is composed of two
polypeptide chains, light (B) and heavy
(A), with a molecular weight of 75,000.
It is the major proteolytic enzyme
involved in blood clot retraction or the
lysis of fibrin and is quickly inactivated
by anti-plasmins. This is an enzyme
that is able to break down fibrin clots
which attach slough and eschar to the
wound bed. This is supported by the
clinical data that indicates that the
attachment points at the edges and
underneath the eschar seem to come
away from the wound (Gray et al,
2005). It is also thought that the
osmotic action of honey may draw
lymphatic fluid from the wound tissue,
this will have the effect of giving a
constant supply of plasminogen at the
interface of the wound bed. It also
washes the surface of the wound bed
from underneath, aiding in the
degradation of the eschar (White and
Molan, 2005).
The successful debridement of wounds
by the use of honey is referenced in
the literature (Cavanagh et al, 1970;
Armon, 1980; Branicki, 1981; Efem,
1998; Subrahmanyam, 1999; Dunford
and Hanano, 2000; Alcarez & Kelly,
2002; Ahmed, 2003; Molan, 2002;
Staunton et al, 2005). This is also
supported by clinical evidence obtained
by Medlock Medical which has showed
successful debridement when other
more traditional methods have failed
(Gray et al, 2005).

Wounds UK 55
Technical INFORMATION
Wound malodour arises in part as a
consequence of tissue necrosis and
associated bacterial infections (Williams,
2001). Malodour in wounds can have a
serious detrimental effect on a patient’s
well-being from a sociological and
psychological perspective (Draper 2005;
Holloway et al, 2002; Bale 2004).
The presence of malodour can cause
immeasurable distress for the patient
and their family and friends, sometimes
causing the patient to be isolated.
The eradication of malodour is very
challenging to the health care profess-
ionals involved in wound management
(Moody 1998).
It has been demonstrated that malodour
can be associated with infected wounds
involving mixed aerobic and anaerobic,
Gram-positive and Gram-negative
microbial populations. (Bowler et al,
1999). This indicates therefore that
absorptive dressings on their own may
not significantly reduce wound malodour
because they do not control bacterial
levels in the wound.
In order to control wound malodour
by the use of dressings two avenues
have been followed by manufacturers.
• First, the use of components (e.g.
activated carbon) in the dressing that
absorb the chemicals that are the
main cause of the malodour (short
chain volatile fatty acids) produced
by the bacteria. These dressings
have met with varying degrees of
success (Thomas et al, 1998; White
and Molan, 2005).
• Second, antimicrobial agents (eg.
silver) in dressing, that targeting the
bacteria that are the main source of
the malodour. These dressings have
been shown to be very effective and
are very popular (Dowsett, 2004),
but concerns relating to toxicity
(Dunn & Edward-Jones, 2004; Lam
et al, 2004; Supp et al, 2005; Cho
Lee AR et al, 2005;) as well as
bacterial resistance (Gupta, 1999;
Silver 2003).
56 Wounds UK
Both raw honey and honey dressings
have been demonstrated to have
antimicrobial effects against a variety
of wound pathogens (Cooper, 2005;
Lusby et al, 2005; Simon et al, 2005;)
including anaerobic bacteria (Efem et
al, 1992; Elbagoury and Rasmy, 1993).
Thus the honey will act against the
primary source of the malodour the
bacteria. Additionally Mesitran has been
shown to be effective against a variety
of wound pathogens (Vandeputte and
Van Waeynburge, 2003).
There are a number of references
relating to the reduction or elimination
of malodour post-application of honey
or honey dressings (Kingsley 2001,
Alcarez & Kelly, 2002; Robson, 2003
Dunford & Hanano, 2004). More
recently case studies that have been
undertaken by Medlock Medical using
Mesitran ointments repeatedly shown
a significant elimination or reduction of
malodour (Gray et al, 2005). This has
greatly increased patient and nurse sat-
isfaction with these types of dressings
(Gray et al, 2005). The deodorising
action of honey is also thought to be
due to the high glucose content which
is used by infecting bacteria in prefer-
ence to amino acids, resulting in produc-
tion of lactic acid rather than ammonia,
sulphur compounds and amines
(Molan, 2005).
Dispersion
When treated with sodium chloride, the
ointment separated into two phases.
Honey contains many components
which may separate out into a more
soluble phase when it comes into contact
with wound fluid. The components that
solubilise within this phase may then
become more available within the
wound environment leading to them
having a greater effect, for example
enhancing debridement, or reducing
bacterial infection.
Honey consists of a variety of
components, carbohydrates, proteins,
amino acids, enzymes, vitamins, and
minerals. It may be that some of the
soluble factors within honey or the
Mesitran ointments are more available
to exert beneficial effects on the healing
process. This hypothesis needs further
development and evaluation.
pH
Mesitran (pH 5.0) may lower the pH
of wounds. This may be important in
the infected wound, in that this level of
acidity would in effect be antimicrobial
in itself (Cooper, 2005).
Conclusion
The results from this laboratory-based
study have shown (confirmed by case
study evaluations) that the Mesitran
range of dressings can be used to treat
the full spectrum of wounds at all stages
of wound healing.
The fluid absorption capabilities of
Mesitran dressings have been shown to
be capable of handling wound exudate
up to that seen in wounds categorised
as ‘heavily exudating’. In addition, a
significant advantage of these dressings
is their ability to lock fluid away within
their matrices thus reducing or prevent-
ing the possibility of tissue maceration.
The Mesitran Mesh, because of its
ability to absorb fluid and gel in situ, will
not adhere to the wound, and can
therefore be used as a primary contact
dressing with the added benefits
supplied by its honey content.
Mesitran ointments, although not shown
to be either donators or absorbers of
fluid, have produced excellent debride-
ment results clinically. The proposed
mechanisms for this have been
discussed, supported by a review of
relevant literature. The debriding
capability of the ointments is thought to
play a part in the malodour prevention
seen when using the product, which
again is supported by Medlock Medical
case study data and substantial
referenced clinical literature.

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58 Wounds UK
 Available
on Drug
Tariff

Healing with honey

Honey is an historic remedy for treating wounds and Mesitran has been shown to have anti-bacterial

has been used in wound management for thousands activity against common wound pathogens including
1
of years, and today there is much well documented MRSA and VRE .

research supporting its use in wound healing.

It debrides wounds – Naturally, reduces malodour –

Mesitran is a NEW hydro-active range of dressings Naturally, creates a moist wound healing

that deliver the therapeutic benefits of honey in environment – Naturally and facilitates good wound

a variety of easy to use presentations, providing a bed preparation – Naturally.

complete solution for all stages of wound healing.

”Mesitran showed exceptional performance in the

management of a patient with Meningococcal
Septicaemia with amazing results.”
Lesley Thorne, Tissue Viability Nurse, Manchester Royal Infirmary.

Mesitran Ointment 15g, 50g • Mesitran Ointment S 15g

Mesitran 10cm x 10cm, 20cm x 15cm, 17.5cm x 10cm • Mesitran Border 10cm x10cm, 15cm x 13cm (Shaped), 15cm x 15cm • Mesitran Mesh 10cm x 10cm

Medlock Medical Ltd., Tubiton House, Medlock Street, Oldham OL1 3HS Web: www.medlockmedical.com
Mesitran is a registered trademark. Patent pending. REFERENCE 1 Data on file. Medlock Medical Ltd
Natural Approaches to Wound Management: a Focus on Honey and Honey-based Dressings. Wounds UK Supplement 1 (3): 1– 60

Medlock Medical Ltd., Tubiton House, Medlock Street, Oldham OL1 3HS Web: www.medlockmedical.com
Mesitran is a registered trademark. Patent pending.